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World AIDS Day: Remembering marginalised and criminalised communities

On World AIDS Day, it's time to think about how people who use drugs are left more at risk of HIV and other blood-transmitted infections.

It’s World AIDS Day today, a day designated to draw attention to the global fight again HIV infections. We’ve come a long way; in less than the span of a single lifetime the world has gone from seeing HIV and AIDS as a death sentence to being in a situation where PrEP (pre-exposure prophylaxis) and PEP (post-exposure prophylaxis) can make a huge difference in protecting people from getting infected or transmitting infections. People living with HIV who have access to effective treatment can lower their viral load to the point of it being undetectable, which also means that it’s untransmittable. Three cheers for science and medicine and healthcare!

There’s still a lot of work to be done and access to healthcare is uneven across the world, but, all things considered, we’re not doing too badly in terms of dealing with HIV and other infections like viral hepatitis. Target 3.3 of the United Nations Sustainable Development goals seeks to “end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases” by 2030. That’s less than a decade away, which seems very ambitious for a very big problem, and it’s not like we’re always that good at meeting global targets (*ahem* climate and environmental targets *ahem*), but it’s not beyond imagination. With scientific research and advancements, and improvements in access to treatment, it is possible to deal with these epidemics. But, as the Global Commission on Drug Policy points out in a recent report: “…because of denial or wilful neglect, many countries have failed to address epidemics among people who use drugs.”

They go on: “Effectively addressing HIV and viral hepatitis among people who use drugs could end both epidemics. One the other hand, the continued failure to systematically confront HIV and viral hepatitis among people who use drugs will thwart global efforts.”

HIV, hepatitis and drug policy reform
HIV, hepatitis & drug policy reform 2023 This report, “HIV, Hepatitis & Drug Policy Reform” follows the Global Commission’s thematic reports on “The War on Drugs and HIV/AIDS” (2012) and “T…

In talking about this issue the focus is generally on people who inject drugs, because that opens the person up to more risks of infections. (In the vast majority of cases, it’s opioids that’s being injected.) Because such drug use is heavily criminalised in many parts of the world, people who inject drugs are driven underground where they are not only exposed to the dangers of unregulated and unsafe supply, but also non-sterile injection equipment. The latter carries the most risk of transmitting infections—a situation further exacerbated by people’s reluctance to seek medical treatment and healthcare due to stigma, discrimination and fears of being caught or reported for their substance use. On top of that, criminalisation also means that people who inject drugs are more likely than the average person to end up in prison, which, in many countries, puts people even more at risk, as the Global Commission’s report points out:

“For people living with or at risk for HIV or viral hepatitis, prisons represent a uniquely risky environment. Unsafe drug injection and unprotected sex (the occurrence of which are frequently denied by prison authorities), sexual violence and tattooing/piercing all facilitate transmission of HIV, HBV and HCV within prison and in the community upon release. For people who are incarcerated while receiving treatment for HIV, viral hepatitis or drug dependence, detention is often associated with treatment interruption. The availability of healthcare in prisons is often subpar, particularly for HIV or viral hepatitis care. Discharge can be extraordinarily hazardous for people who resume opioid use after having ceased while incarcerated, who are three to eight times more likely to overdose due to decreased tolerance. Increased risks persist after release—recent incarceration is association with an 81% and 62% increased risk of HIV and HCV acquisition, respectively.”

I tried to look up the situation in Singapore and couldn’t find a huge amount of data, but I did find this study. They found that “prevalence of BTIs [blood transmitted infections] was significantly lower than that reported among most drug-using populations in international data”, but also that “patients with lifetime IV drug use were found to be more than four times more likely to have a BTI-positive status, and the prevalence of BTIs in our study cohort was significant higher than that of the local population.” (They also recognised that “incarcerated drug users would not have been captured in the present study and these users would constitute a potentially higher risk group”, so that’s worth keeping in mind.) The alarm bells might not be blaring as loudly in Singapore as they do in some other countries, but it doesn’t mean that there aren’t vulnerable communities that are more at risk.

Previous issues of Altering States have already pointed out the harms of the War on Drugs and the importance of harm reduction work (I published a couple of interviews here and here). I’ve already written about how prohibition and criminalisation leaves people who use drugs more exposed and unsafe, and argued, on that basis, for the urgent need for drug policy reform that moves away from this war on people associated with drugs.

But I often wonder how compelling that argument is to many people. Sometimes I get the sense that when we talk about prioritising “keeping people safe”, what we mean is keeping people who don’t use drugs safe while we dismiss and condemn those who do (or worse, keeping people safe from people who use drugs, which further perpetuates social stigma and hate). We see those who are already using drugs as “criminal” and less deserving, blaming them for their devastating and traumatic run-ins with the law, for their incarceration, for their ostracisation from society, for their health problems, and even for their own deaths. While it’s true that people need to be accountable for their choices and decisions, we not only overly individualise the issue of drug use but do it in a way that is more often than not de-contextualised from even that person’s lived experiences, traumas and struggles. We are highly aware of our own hardships and challenges, yet dismiss, minimise and overlook those of people who use drugs. Perhaps, when we talk about “keeping people safe”, we don’t consider people who use drugs because our War on Drugs mindset has conditioned us to stop thinking of drug users as people, leaving us unable to comprehend the intertwined and interconnected nature of our lives as communities and societies.

If this is the case, it becomes even clearer that the War on Drugs is a war on people, and the problem goes far, far deeper than this or that substance. But if our motivation for going to war with drugs is to keep people safe, healthy and thriving—and I think a lot of people do care about this—then we must pay attention to experts when they say that prohibition and criminalisation is hampering efforts to end epidemics.

People living with HIV still face stigma and discrimination in this world, often tied in with other prejudices about gender, sexual orientation, sexual activity and more. Despite that, strides have been made to change public mindsets and attitudes, provide better access to treatment and improve health outcomes. The progress we’ve made in these areas show that we can hope and be optimistic that things can get better. If we can improve things in one area, surely we should be able to do it in others as well, and adopt better approaches that allow us to live in societies where when we talk about “people”, we really mean everyone.

I hope that, with every World AIDS Day, we move closer and closer towards a gentler, more loving world that leaves no one behind.

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