Is the war on drugs crippling the war on AIDS? And might the AIDS epidemic make governments more willing to treat drug abusers as suffering patients rather than as hardened criminals?
Those questions came to the fore last week because of a fumbled news story. It was announced — incorrectly, it turned out — that the United Nations Office on Drugs and Crime, which oversees the fight against cross-border drug trafficking, was about to do a startling about-face and advocate ending penalties for personal use of all drugs.
The schisms revealed by the news — U.N. agencies, not to mention nations and political parties, are sharply divided over the issue — showed how the debate is shifting, in part because of H.I.V.
The spread of virus through needles may be the least-talked-about but most intractable aspect of the AIDS epidemic. In North America and Western Europe, H.I.V. is mostly transmitted through gay sex. In Africa, the focus of most Western aid, it is spread through heterosexual sex.
But in many countries — notably Russia and Eastern Europe, and across swaths of Asia where the opium poppy flourishes, the greatest H.I.V. risk is injected heroin.
“Our position is very clear,” said Michel Sidibé, the executive director of Unaids, the U.N. agency fighting AIDS. “Of the 12 million people who inject drugs, 1.7 million are infected. We need to take these people out of the shadows and into services, or we will never control the epidemic.”
Studies done decades ago on groups with different H.I.V. risk factors — prostitutes in Nairobi, gay men in San Francisco and addicts in Bangkok, for example – showed that needle-sharing was the fastest way the virus spread when it entered a new population.
Around the world, users who inject drugs are 28 times more likely to be infected than people who do not.
Taking away the fear of arrest after being caught with a syringe or a gram of heroin makes it possible for addicts to sign up for risk-lowering interventions: clean syringes, condoms for those who sell sex for drugs, antibiotic treatment for venereal diseases, methadone to help addicts lead less chaotic lives, antiretroviral treatment and pre-exposure prophylaxis.
Jailing users, by contrast, increases risk. Many prisons are H.I.V. hotbeds because of drug needles, tattoo needles, unprotected male-male sex and rape.
No two countries have matching policies on the nonmedicinal use of drugs.
In the United States, marijuana is legal in four states while heroin is universally outlawed; 30 states allow syringe exchanges while 20 do not. In Switzerland, by contrast, voters in 2008 effectively made heroin a medical problem, but kept marijuana illegal.
Iran permits clean syringes and methadone, even to prisoners. Heroin addicts, who once faced the death penalty, are immune from arrest while in treatment.
Study after study has shown that countries that reduce penalties and offer treatment have reduced H.I.V. infections. China, for example, dropped a zero-tolerance policy on heroin in favor of clean syringes and methadone. It now has 700 clinics treating 200,000 patients, and new H.I.V. cases among those patients have dropped by 90 percent, Mr. Sidibé said.
In 2001, Portugal made the possession of up to 10 days’ worth of any drug legal. Only 78 H.I.V. cases there were attributed to drug use in 2013. (Also, overdose deaths are now among the lowest in Europe — 3 per million Portuguese versus 45 per million among residents of Britain, for example.)
In Germany, arrests on charges of possession of small amounts may be dismissed. Most addicts are in treatment, and pharmacies sell syringes cheaply.
Germany has about 3,300 new H.I.V. infections a year; only about 100 of them from drug use — down from 1,200 in 1986. Many are in recent émigrés from former Soviet countries, according to a 2012 Unaids report.
In Russia, by contrast, under President Vladimir V. Putin’s “traditional values” campaign, the police crack down hard on addicts. Syringe exchanges and methadone are illegal. State hospitals rely on detoxification and group therapy.
Lord Fowler, a former British health secretary, said in a recent BBC magazine article that he chief of Moscow’s major “narcology research” hospital told him that half the addicts she treated relapsed within a year, and 90 percent within eight years.
Russia has 85,000 new H.I.V. infections a year, and the head of Moscow’s Federal AIDS Center said in May that 57 percent were from drug injection.
Questions over drug policy have split U.N. agencies. The World Health Organization and Unaids openly favor ending criminal penalties to fight H.I.V.
But U.N.O.D.C., the drug and crime agency, rooted in law enforcement and the 1946 U.N. Commission on Narcotic Drugs, is more conservative. Its executive director, Yury Fedotov, is Russian; high U.N. officials rarely flout the views of the governments that nominate them.
The agency’s H.I.V. division did produce a briefing paper last week saying that possession of small amounts could be made permissible under anti-trafficking treaties and human-rights law. An agency representative denied that it amounted to a reversal of 70 years of policy said such a momentous change would not be announced “by a midlevel official at someone else’s conference in Kuala Lumpur.”
However, a shift by the United Nations as a whole may be in the wind.
Even Secretary General Ban Ki-Moon recently treaded close to the line, saying, “We must consider alternatives to criminalization and incarceration of people who use drugs.”