International Journal of Drug Policy - 2015

Volume 26 Supp 1 Feb 2015

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Page 34 of 47

International Journal of Drug Policy 26 (2015) S27–S32 Contents lists available at ScienceDirect International Journal of Drug Policy j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / d r u g p o Commentary HIV, drugs and the legal environment Steffanie A. Strathdee a,∗ , Leo Beletsky b , Thomas Kerr c a University of California San Diego, La Jolla, CA, USA b Northeastern University School of Law and Bouvé College of Health Sciences, Boston, USA c University of British Columbia, Canada a r t i c l e i n f o Article history: Received 14 June 2014 Received in revised form 29 August 2014 Accepted 4 September 2014 Keywords: HIV Law Policing Injection drug use Harm reduction a b s t r a c t A large body of scientific evidence indicates that policies based solely on law enforcement without taking into account public health and human rights considerations increase the health risks of people who inject drugs (PWIDs) and their communities. Although formal laws are an important component of the legal environment supporting harm reduction, it is the enforcement of the law that affects PWIDs' behavior and attitudes most acutely. This commentary focuses primarily on drug policies and policing practices that increase PWIDs' risk of acquiring HIV and viral hepatitis, and avenues for intervention. Policy and legal reforms that promote public health over the criminalization of drug use and PWID are urgently needed. This should include alternative regulatory frameworks for illicit drug possession and use. Changing legal norms and improving law enforcement responses to drug-related harms requires partnerships that are broader than the necessary bridges between criminal justice and public health sectors. HIV prevention efforts must partner with wider initiatives that seek to improve police professionalism, accountability, and transparency and boost the rule of law. Public health and criminal justice professionals can work syn- ergistically to shift the legal environment away from one that exacerbates HIV risks to one that promotes safe and healthy communities. © 2015 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license ( Introduction When asked why they shared a syringe, a common response from people who inject drugs (PWIDs) is "I had no choice." Sharing syringes and other injection paraphernalia, which increase the risk of acquiring HIV and viral hepatitis are behaviors that do not occur in a vacuum. These and other risk behaviors are shaped by factors at macro, meso and micro level of the physical, social, legal and pol- icy environment (Rhodes, Singer, Bourgois, Friedman, & Strathdee, 2005) that affect PWIDs' access to syringes and addiction treatment. In this commentary, we discuss factors in the macro and micro-legal environment that are known to increase transmission of HIV and viral hepatitis among PWIDs, as well as structural interventions that can be used to prevent these infections. There is now a large body of empirical evidence demonstrating that formal laws and policies are critical aspects of the environ- ment influencing HIV risks among PWID. At the macro-level, most countries have laws and policies that dictate whether drug pos- session and use are punishable by law and to what extent. In response to numerous and consistent indicators that the 'war on ∗ Corresponding author. Tel.: +1 858 822 1952. E-mail address: (S.A. Strathdee). drugs' is ineffective (Beyrer et al., 2010; Reuter, 2009; Wood et al., 2010; Wood, Werb, Marshall, Montaner, & Kerr, 2009), includ- ing unchanging availability and use of drugs and various severe health-related harms (Werb et al., 2013), at least 30 countries are reforming drug policies to align them more closely with public health goals (Cozac, 2009; Hughes & Stevens, 2007; Moreno, Licea, & Ajenjo, 2010), and even some U.S. states. On the other hand, harsh penalty-based drug policies remain in place in many other countries, and in some cases have been strengthened of late. In twelve countries, legislation allows judicial corporal punishment for drug and alcohol offences (e.g., death penalty), which is a vio- lation of international law (IHRA, 2011). Some countries maintain compulsory 'drug detention' programmes (Global Commission on Drugs, 2012; HIV and the Law, 2012) which often operate as forced labor or military training camps, and where evidence-based addic- tion treatment is entirely absent. These punitive policies have been associated with elevated risk behaviors and detrimental health outcomes among PWID (Degenhardt et al., 2010). Human rights elements of these policies (Wolfe & Cohen, 2010) are addressed in the thematic paper by Kamarulzaman and colleagues in this issue. In 2009, the World Health Organization, UNODC and UNAIDS identified nine HIV interventions as scientifically proven, essen- tial components of a combination package to prevent HIV among PWID. These include provision of sterile syringe access through 0955-3959/© 2015 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (

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