Global Fund submission to the UNGASS process
The public health imperative for rights-based drug control policy: A statement for the UN General Assembly Special Session on the World Drug Problem
The Global Fund to Fight AIDS, Tuberculosis and Malaria
April 2016
The Global Fund to Fight AIDS, Tuberculosis and Malaria welcomes the UN General Assembly Special Session on the world drug problem as an opportunity to bring public health and human rights concerns to the center of drug control policy.
The Global Fund was created as a partnership. Working together, over the past 15 years, we have contributed to great progress in the fight against HIV, as well as TB and malaria. Through a collective effort, combining the contributions of governments, civil society, the private sector and affected communities, the Global Fund disburses nearly $4 billion per year to support local programs that prevent infections and the premature deaths of millions of people from HIV, TB, and malaria.
The HIV response over the past 15 years has been tremendous. In 2000, there was no global public health response to the HIV epidemic. In 2016, almost every country around the world is implementing prevention and treatment programs. Just as important, there is widespread recognition that HIV discriminates, and does not affect people equally. The community of people who use drugs in all their diversity, including women, men, trans* and young people, have been left behind in the global response.
To end the HIV epidemic, we must do more to prevent HIV and other infections among people who use drugs, and ensure that those living with HIV and other infections have access to care, treatment and support. We need to recognize that the level of criminalization, discrimination, and violence that people who use drugs face, can only result in driving risk-taking behaviors, including in detention settings, excluding them from the social and health support systems they need. We must move toward treating everyone, including people who use drugs, as fellow human beings.
As a health financing institution that aims to invest in evidence- and rights-based programs that provide the greatest value for money, we add our voice to that of our technical partners, in particular, UNAIDS and WHO, and express our concern that current drug control policy undermines, rather than supports, the reach and impact of health programs for people who use drugs. Experience and evidence show that the International Community could do much better and dramatically improve health and human rights outcomes.
Opportunities and solutions
The UNGASS on the world drug problem has the opportunity to rethink policies that undermine health programs and to shape drug policy that will facilitate good health outcomes. Good drug policy can help in many ways, including:
• by ensuring adequate investment in essential, cost-effective health services for people who use drugs, including comprehensive HIV, TB, and Sexual and Reproductive Health services;
• by supporting the meaningful participation of people who use drugs in health programs;
and
• by ensuring that resources are used for programs that minimize health harms and protect human rights, rather than incarceration of large numbers of people who use drugs.
Essential HIV and TB services for people who use drugs : A large body of evidence shows that needle and syringe programs (NSP) and opioid substitution therapy (OST) are among the most effective and cost-effective prevention and treatment programs in the world – and among the most widely evaluated. (See annex to this statement for a summary of some key research.) People who inject drugs readily utilize harm reduction services when programs are welcoming and non-judgmental. NSP services have the additional benefit of refering people who wouldn't attend mainstream services to other services to address and manage their health and social needs. Many countries have found that NSP yield significant returns on investments, over reduced burden of HIV care on health systems. OST is a not only highly effective in treating opioid dependence but also helps prevent HIV and hepatitis as well as overdose by reducing the frequency of injecting. OST also reduces crime and social instability. Investment in NSP and OST – combined with HIV treatment for people living with HIV who use drugs – is good public health practice, fiscally responsible, and part of the fulfillment of states’ human rights obligations to their citizens. NSP and OST services in prisons and in the community are both crucial.
Although data are incomplete, evidence also suggests a substantial and growing population of women injecting drugs worldwide. Women and men have different experiences of injecting drug use and related risks and harms. Even within a community that faces high levels of violence and social exclusion, gender shapes the way people access and receive services. As a result, women who use drugs have significantly higher rates of morbidity and mortality ascompared to their male counterparts, and in particular higher rates of HIV infection. Gender sensitive harm reduction programs are therefore critical to ensure equitable access to services and to address the significant overlap between gender, drug use, sex work, and nonconforming gender identities. The Global Fund urges member states to deal with the issue of gender in the context of drug use as key to ensuring equitable access to services as part of their obligation to their citizens.
In spite of the preponderance of public health and economic evidence for harm reduction interventions, including some notable examples from programs implemented with Global Fund resources, investment in them remains far too low, particularly from national resources, and reliance on external resources such as the Global Fund is unsustainable in the long-term. As a result, a very small percentage of people who use drugs in the world have regular access to NSP and OST; and it is estimated that up to 86% of people who inject drugs who are living with HIV lack access to antiretroviral therapy. The Global Fund urges member states at the UNGASS to support drug policies that enable scale-up of these services.
In some countries, people who use drugs are still held in centers purporting to provide “treatment” or “rehabilitation,” with widely reported violations of human rights, little or no judicial process or medical evaluation of those held, and no evidence of effectiveness. In 2012, twelve UN agencies called for the closure of all compulsory treatment facilities, including compulsory drug detention centers. The Global Fund has made repeated calls for the closure of drug detention centers while expressing concerns that those detained illegally within them must not be denied access to essential health care. In October 2014, the Global Fund Board decided that the Global Fund would not fund any interventions in compulsory drug detention centers. The Global Fund urges member states at the UNGASS to call for the immediate closure of all drug detention centers, in line with the call made by the United Nations in 2012.
People who inject drugs are also at high risk of TB in many settings, and HIV and TB co-infection is very high among them. As WHO experts note, criminalization and penalization of minor drug offenses undermine national TB responses. People who use drugs who fear that seeking health services will put them in the path of the police are less likely to be reached by TB testing or to complete treatment. Moreover, prison and pretrial detention are very high-risk environments for TB and multi-drug-resistant TB (MDR-TB) in many countries. Overcrowding and poor sanitation and ventilation in prisons contribute to the risk of airborne transmission, and access to testing and treatment is often limited. Global Fund-supported programs have shown that the high TB risks in the prison environment can be effectively addressed by sustained investment in prevention and care, especially when there is continuity of services between prisons and the community.
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