Drug Decriminalisation Holds the Key to Ending AIDS Among People Who Use Drugs

Written by

Mat Southwell, Managing and Technical Director of Coact Technical Support UK

Alexei Lakhov, Coact Consultant Coact Technical Support and high-level advocate

This article is part of a series responding to the Joint United Nations Programme on HIV/AIDS, the United Nations Development Programme, and the International Network of People who Use Drugs' guidance note 'Decriminalization of drug use in the context of HIV.'

Read the companion piece by Catherine Cook here.

Punitive drug control laws, policies and policing practices have been shown to be a barrier to healthcare, deterring people from accessing harm reduction services and carrying harm reduction materials. This punitive environment encourages people to rush the preparation and administration of their drugs. The result? More fear, more injuries, more sharing of needles, more transmission of HIV and viral hepatitis, and more drug-related deaths.

A new resource from the United Nations, Decriminalization of drug use in the context of HIV: a guidance note (Guidance Note), pulls together the lessons learned from different models and approaches to the decriminalisation of drug use and possession for personal use within the context of the HIV response. It highlights how some models can support the HIV response while others may repeat the harms of criminalisation. The resource, developed in partnership with UNAIDS, United Nations Development Programme and the International Network of People who Use Drugs (INPUD) will support countries to develop effective models of decriminalisation that have their foundations in public health and human rights. It provides key principles and good practices from the various models reviewed, as well as the experiences and expertise of people who use drugs, academics, health service providers and other experts.

Ending criminalisation protects health

Over the last 25 years, drug user advocates have worked with representatives of people living with HIV, other key populations such as sex workers and trans people who are affected by HIV, and wider HIV civil society to advocate for action that puts communities at the heart of the response.

This sustained community advocacy resulted in a Global AIDS Strategy 2021–2026, and, this year, the Global AIDS Strategy 2026-2031, which includes bold targets for affected communities to be directly involved in the prevention, testing, treatment, and advocacy for HIV. For over 15 years, UNAIDS has also recognised the importance of repealing laws targeting people who use drugs. This growing focus on ending criminalisation to end AIDS has already led 39 countries to adopt decriminalisation although the forms and definitions vary significantly. The strategy also includes a specific target that by 2025, only 13 countries will still have laws criminalising the possession of small amounts of drugs. This recognises that decriminalisation of drug use and possession for personal use is key to creating the legal enabling environment to end HIV among people who use drugs.

Importantly UNAIDS and WHO recognise that when decriminalisation of drug use and possession for personal use is combined with harm reduction strategies, people who use drugs have improved HIV and other health outcomes, are supported to engage in prevention and treatment services, and this reduces HIV transmission rates.

People who use drugs shape new guidance

The central role of INPUD in gathering the learning from the wider drug user community to inform the Guidance Note illustrates how global decision-making actively embraces the testimony and experience of people who use drugs around the world. It recognises that meaningful community participation requires investment and capacity building to support the drug user rights movement to play its critical partners in designing the response to HIV.

In 2010 INPUD launched the Drug User Peace Initiative to call for an end to the war on drugs. Inevitably the war on drugs has been waged against people who use drugs and this drives drug users underground, away from services and into harmful drug taking practices.  If people who use drugs are to be meaningful partners in ending AIDS, then governments need to accept that the war on drugs has done far more harm than good. If we are to find our way out of this public health and human rights crisis then people who use drugs need to be brought in from the margins and given a space at the policy table.

Tackling HIV and drug use in the UK

In 1986, the early data from Edinburgh suggested that HIV was already widespread among people who inject drugs in the UK.  Politicians feared that people who inject drugs would become a “bridge” for HIV to spread through their sexual partners into the general population. This was the driver for change that created the conditions for the Conservative Government to fund a national needle and syringe programme (NSP) pilot with 15 drug services in England and Scotland where “evaluation was an integral part of the experiment. ” The findings from this national pilot informed the recommendations of the first Advisory Council for the Misuse Drugs (ACMD) AIDS and Drug Misuse report. Their statement that “The spread of HIV is a greater danger to individual and public health than drug misuse” established an important principle that underpinned the development of NSP and harm reduction with people who inject drugs in the UK.

The UK’s pragmatic response was driven by a fear that people who inject drugs would become a “vector for HIV” to spread from a population living on the margins into the general population. This driver for change resulted in bold public health thinking and investment. It turned out that Edinburgh was an outlier city where policing strategies had restricted access to sterile needles and syringes, which resulted in widespread sharing of used needles and syringes creating the optimum conditions for the transmission of HIV.

The UK’s rapid, strategic and evidence-based response to HIV was an incredible success saving lives and money. Importantly, for a period the ACMD was trusted to guide the UK’s response to HIV and its three cutting-edge AIDS and Drug Misuse Reports underpinned the development of a harm reduction infrastructure and saw the scale up of opioid agonist maintenance therapies such as methadone and buprenorphine.

Tragically for people who use drugs in the UK, successive Westminster governments have taken us further away from the traditions of the British Model and the principles of harm reduction. The result? The highest drug related deaths in Europe, a new HIV outbreak among people who inject drugs in Glasgow in 2015, and the fracturing of the therapeutic alliance between people with opioid dependence and drug treatment providers. The Westminster government forced people who use drugs into abstinence by paying incentives to drug services if they managed to get drug users off drugs for six months. The consequences of policies that prioritised treatment exit over long-term support likely contributed to increased drug-related deaths, reduced trust in services, and poorer engagement with HIV and hepatitis C prevention. 

This failed strategy has been recalibrated somewhat after the Black Report exposed the UK’s systemic social health inequities and highlighted the devastating ideological and financial assault on the once famed British Model. Over time, people who use drugs have moved from “vectors of disease” to service users and now recovery champions. Community voices are used to justify policies that have evidently failed.

Russia’s deepening drug crisis

Russia has long advocated for strict crackdowns on drugs. Russia prohibits opioid agonist maintenance treatment and uses its sweeping "foreign agents" and anti-propaganda laws introduced in 2012 to heavily restrict civil society, independent media, and human rights.  Reduced state funding and strict monitoring of and limitations external funding are combining with crackdowns on the activities of civil society organisations to severely diminish Russia’s HIV response. In 2021, Russia accounted for nearly 4% of new HIV infections worldwide, which is the highest share in the European region and the fifth highest globally. Russia’s HIV epidemic has historically been concentrated among key populations but in 2023, 16 regions of Russia reported that the proportion of pregnant women with HIV had exceeded 1%, the threshold that is considered suggestive of a generalised epidemic. The criminalisation of key populations creates conditions that risk further expansion of HIV into the general population.

Russia’s war with Ukraine has further degraded healthcare system in the country.  Russia led the opposition to the Global AIDS Strategy and its focus on public health, human rights and communities. Russia’s HIV epidemic is already impacting the general population compounded by the additional challenges of being a country at war. In Russia, drug user advocates are seen as foreign agitators threatening the nation state.

What Scotland is teaching us about rights based, public health-led decriminalisation?

In 2023 Angela Constance, the then Scottish Drugs Minister attended the Commission on Narcotic Drugs (CND) and met with INPUD and representatives of drug user advocates from around the world. The meeting reflected Scotland’s embracing of a drug policy founded on human rights and public health principles and a recognition of the importance of listening to people who use drugs. 

In 2021 The Scottish Government published its Medication Assisted Treatment (MAT) standards: access, choice, support to “ensure that people have immediate access to the treatment they need with a range of options and the right to make informed choices.”

Importantly, Scotland is tackling drugs while addressing the underlying determinants of health, taking an approach that also addresses poverty reduction, the struggle for racial justice, and the wider criminalisation of other key populations who also use drugs. The rights of people who use substances and Scotland’s commitment to participation is framed within Charter of Rights for People Affected by Substance Use. Significantly, the Charter draws from the International Guidelines on Human Rights and Drug Policy, which sets out best practice as identified by the UN.

The Scottish Government has proposed decriminalising possession of all drugs for personal use to tackle one of Europe’s highest overdose death rates. The barrier to progress remains the Westminster Government’s continued commitment to prohibition despite growing global recognition that such policies have failed and undermine public health goals.

The Scottish Drugs Forum has supported a rolling dialogue with people who use drugs gathering their views and strengthening the capacity of people with living experience to contribute to the review, development and delivery of drugs policy and practice. Scotland highlights the potential to shift the role of people who use drugs in a national dialogue about drugs policy and practice. The transition from criminal to patient to rights bearer marks a significant shift in roles and relationships.

Reasons for hope

The UN’s new drugs and HIV Guidance Note is a practical review of the evidence from those countries that have attempted decriminalisation. No country has achieved a perfect model of decriminalisation, but important lessons have been learned that can inform other countries’ development of decriminalisation driven by human rights and public health principles.  

Critically people who use drugs should be supported and resourced to meaningfully participate in the development, implementation and monitoring of the decriminalisation of drug use and possession for personal use. This is key to ensuring that future models of drug policy reform do not repeat the mistakes of criminalisation.

Mat Southwell (UK) and Alexei Lakhov (Russia) both been harm reduction managers and were previous Executive Directors of the European Network of People who Use Drugs (EuroNPUD). Both have worked as technical consultants as part of the United Nations response to HIV and people who use drugs, and served as European NGO Delegates to the United Nations Joint Programme on AIDS (UNAIDS) Programme Coordinating Board (PCB). They are currently working with Frontline AIDS as part of a Unitaid-funded study into hepatitis C elimination in low and middle- income countries where communities are playing a central role. Together they review UNAIDS new Guidance Note on decriminalisation as part of the HIV response.