OVERVIEW: DRUG-USER HEALTH IN A HUMAN RIGHTS FRAME
“Drug users are vulnerable people. They suffer from inadequate medical assistance. They experience discrimination, invasion of privacy, police harassment, and social marginalization. They have to endure arbitrary deprivation of rights, such as mandatory medical treatment. Their capacity to defend their interests is impaired by social stigmatization. One would assume that society's majority would oppose such violations. After all, arbitrary searches, nightclub raids, compulsory urine tests, and wrongful appropriation of confidential medical files are injustices suffered by nonusers as well. But the majority accepts the invasion of privacy in an attempt to have a drug-free environment”-Judit Fridli, Chair, Hungarian Civil Liberties Union, 2003.
Efforts to provide HIV prevention, treatment, and care to injecting drug users (IDU) are shaped by a basic tension. On the one hand, public health agencies and clinicians recognize that drug-dependent individuals suffer from a chronic and relapsing condition. On the other, law enforcement officials pressured to curb demand and supply for illicit drugs regard IDU primarily as participants in illegal exchange, rather than as individuals in need of services. These tensions are borne out in policies that simultaneously seek to increase access for IDU to prevention and treatment services and to reduce demand for illegal drugs through punitive measures, including arrests and imprisonment. Conflicting strategies are frequently pursued simultaneously in developed and developing countries alike, and at the international level where tensions between those who call for a “drug-free world” and those who urge public health approaches to contain drug dependence and HIV have led to what some have called “double vision,” “systematic incoherence” or a “dis-United Nations.”1,2
HIV/AIDS attributed to injecting drug use is currently reported in 119 countries, and IDU account for nearly one-third of new HIV infections outside sub-Saharan Africa.3 The need for a public health response to the intertwined epidemics of drug abuse and HIV is clear, and fortunately, so is the evidence on the best practices available to contain them. Provision and exchange of sterile injecting equipment is among the most thoroughly studied and effective of these, having been demonstrated to reduce the spread of HIV by taking contaminated syringes out of circulation without encouraging or increasing drug use.4 Methadone and buprenorphine, prescribed as opiate substitution therapies (OST), are effective in reducing craving and use of opiates and have been added to the list of essential medicines by the World Health Organization (WHO).5 Citing evidence that IDU, when offered HIV testing and antiretroviral (ART) adherence support, can achieve significant virologic benefits,6,7 WHO has issued guidelines for the use of first-line and second-line ART for IDU, with instructions that drug users should not be denied treatment on the basis of their IDU history or active drug use.8 In countries such as the Netherlands, Switzerland, and France, a combination of HIV prevention and treatment, including prescriptions for OST to treat opiate dependence, have reduced HIV incidence among IDU to nearly zero.9,10 Although the preventive potential of universal ART access (“treatment as prevention”) has yet to be adapted and evaluated for sexual, much less parenteral, transmission of HIV, preliminary findings suggest its effectiveness among IDU. In a Vancouver cohort of IDU, researchers found that reductions in community HIV-1 RNA levels as a result of ART correlated significantly with reduced HIV incidence, independent of unsafe sexual behaviors and sharing of used syringes.11
The political viability of comprehensive global HIV prevention and treatment for IDU remains an open question. IDU account for the largest share of cumulative HIV infections in 20 countries of Eastern Europe and Asia.12 In most of these where data are available, IDU represent a minority of those on ART, despite being the majority of those in need.12-15 Although “universal access” to HIV prevention and treatment is affirmed by many governments and international organizations,16 needle exchange and methadone treatment programs in many low-income and middle-income countries remain few in number, underfunded, and constrained by regulation and lack of political will.12,17 In Russia, OST for opiate addiction is banned by law. IDU and outreach workers in countries as varied as Bangladesh, Kazakhstan, India, Indonesia, and Ukraine, experience denial or confiscation of essential medicines, extortion, planting of evidence, and arbitrary detention by police.18-27 “Harm reduction is like a sandcastle,” a Malaysian peer educator active in syringe provision told an international conference last year. “Community builds it up, and law enforcement tears it down.”28
HUMAN RIGHTS AND HIV PREVENTION AND TREATMENT FOR IDU: A SHARED FRAMEWORK
Increasingly, scientists have been looking beyond individual IDU to their “risk environments,” the various physical, geographic, social, economic, and political structures that influence IDU risk behaviors and adverse health outcomes.29-31 Some have urged attention to the “case of the missing cop”: the effects, often unacknowledged, of criminal law and law enforcement on IDU risk for overdose, treatment interruption, and HIV or other blood-borne infections.32 Police crackdowns, arrests, and incarceration are correlated with hurried injections, sharing of injection equipment, treatment interruption, and other adverse health effects.33-37 Policies and practices in health care settings, including denial of ART to current or former IDU,12,33,38 erroneous physician assumptions about patient compliance,39,40 and lack of access to methadone treatment for IDU requiring hospitalization or tuberculosis treatment12,41 have been shown to impede an effective HIV response. In multiple countries with injection-driven HIV epidemics, those most in need of drug-dependence treatment or ART are required to have their names placed in registries to access public clinics. Registries are shared with the law enforcement, and those registered subjected to mandatory drug testing and stop-and-frisk actions by the police,42 and to denial of employment, driving licenses, and child custody.43 Fear of being added to such registries is a major barrier to IDU in need of health services.19,43-46
Researchers and health providers who work with IDU have long examined the nexus of service provision, risk environments, and human rights. The most elemental concerns of human rights law are also determinants of the health outcomes of IDU, including incarceration, violence, stigmatization, isolation, and discrimination. A second generation of human rights standards protects economic and social rights including “the right to the highest attainable standard” of health. While human rights advocates generally draw upon a different set of normative standards from those used by health providers-they are more likely to cite the Universal Declaration of Human Rights or one of the 9 cornerstone, legally binding international human rights conventions47 than they are guidelines from the WHO or the National Institute on Drug Abuse-yet they have found common cause with those working to reduce the adverse health impacts of illicit drug use.48-50 Core principles of human rights include liberty and security of the person, autonomy, privacy, and freedom from cruel, inhuman, or degrading treatment. These clearly overlap with elements of effective health programming for IDU, where client trust and the building of “therapeutic alliances” have proven critical.51,52 Researchers and health providers working with IDU have long recognized the importance of understanding how hostile police environments impact individual risk behaviors.53-56 Health services are ineffective if people are unable or afraid to use them.
As debates over provider-initiated HIV testing make clear,57,58 the pragmatic alliance between public health and human rights continue to be tested. The emphasis by human rights advocates on limiting state action rankles both public health officials concerned that protection of individual liberties such as informed consent will impede protection of public health, and policymakers who believe that national policy should not be dictated by multilateral agreements monitored in foreign capitals.59 Human rights proponents differ as well over the degree to which the concept of the “right to health” should be used to influence decisions on allocation of resources by national governments.60,61 In the case of HIV, however, explicit commitments to universal access to HIV prevention and treatment, and recognition that constraints on individual liberty in the name of law enforcement impede public health, are clear points of convergence for advocates of health and human rights. The special concern of human rights conventions toward such vulnerable groups as women, children, racial and ethnic minorities, persons with disabilities, and those in prison or other custodial settings also resonates with HIV prevention and treatment professionals who are increasingly focused on “most at-risk populations.” Table 1 provides a shared framework where human rights principles and best practices for HIV prevention and treatment for people who inject drugs can be seen to converge (Table 1).
The importance of human rights protections in HIV services is underscored by the epidemiology in places where these protections have been ignored. In Thailand, for example, a 2003 government-sponsored war on drugs led to arrest quotas, blacklists, forced drug testing, the detention of more than 50,000 people in military-run “treatment camps,” and the death of more than 2800 individuals in what human rights experts termed “extrajudicial executions.”68 Researchers and HIV service providers reported dramatic declines in participation in clinical trials and HIV prevention programs, although HIV infection rates among IDU continued unabated.69 In Russia, the United States, and many other countries, prolonged imprisonment and pretrial detention of drug users for nonviolent offenses concentrates HIV-infected and uninfected individuals in penitentiary settings where HIV risk behaviors continue but where basic precautionary measures to prevent HIV, such as condoms or sterile injection equipment, are unavailable. The obvious result is that needle sharing and unsafe sex occur, with ensuing spread of HIV among inmates in the institution and eventually into the wider community when they are released.70-72
Even when guided by evidence, the health benefits of HIV prevention for IDU do not always translate to increased popular or political support. As recently as January 2010, after years of declines in HIV prevalence among New York City IDU as a result of needle exchange and safer injection education,73 a special narcotics prosecutor and chair of the City's Council's public safety committee charged that a Department of Health publication on safer injection was a “how-to manual” for drug use and should be withdrawn.74 Table 2 explains why this and other health-deterring approaches may violate international human rights conventions and basic human rights.
SOCIAL DETERMINANTS AS HUMAN RIGHTS VIOLATIONS? THE CASE OF ARBITRARY DETENTION
In virtually all low-income and middle-income countries, greater numbers of IDU are found in prisons, pretrial detention facilities, police lock-ups, and forced rehabilitation centers than in the health system.20 Although the exact numbers are unknown, estimates are that 30% of prisoners worldwide are drug users who have never been tried or convicted of any offense.76 In Asian countries such as China and Vietnam, an estimated 400,000 drug users or more are interned in “detoxification” or “rehabilitation” centers where they spend 2 years or longer without criminal charges, appearance before a judge, right of appeal, or evaluation by an addiction treatment professional.20
Pretrial and arbitrary detention subject detainees to numerous health risks associated with overcrowding, violence, physical and psychological abuse, and poor infection control. Asian drug-detention centers are run by police and the military. They provide no evidence-based treatment for drug dependence and limited or no treatment for HIV or tuberculosis, despite the high prevalence of these infections. In China and Vietnam, those who test positive for illicit drug use are forced to labor in the service of private companies, and beatings, food deprivation, and even torture are punishments for those who fail to meet production quotas or attempt to escape.20 In all countries, detainees are most at risk for beatings, torture, or cruel and degrading treatment immediately after their arrest. Police in Ukraine and Kazakhstan have reportedly used the threat of painful withdrawal symptoms to coerce confessions from drug-dependent individuals.23,25 This has been identified as torture by a United Nation (UN) special rapporteur.77 Detention environments that contribute to infection and death have also been identified as sites of multiple other violations of human rights, including the right to due process, the right to health, and when detainees die without medical attention, the right to life.78,79
Identifying arbitrary and pretrial detention practices as human rights violations may also lead to practical, political, and structural improvements. In recent cases before the European Court of Human Rights, the governments of Ukraine and Russia were ordered to compensate the families of drug users who had died in pretrial detention, thus increasing pressure on the governments to improve health in detention; the Court also ordered the release of detainees suffering life-threatening conditions.80,81 The European Court found the Republic of Georgia negligent for not providing hepatitis C treatment to a detainee infected while in prison.82 The Standard Minimum Rules on the Treatment of Prisoners,83 together with independent monitoring bodies such as the Committee on the Prevention of Torture and the Working Group on Arbitrary Detention, have exerted additional pressure on governments to make needed reforms to reduce overcrowding and attendant health effects; these reforms may include the provision of legal aid, standardization of bail policies at the pretrial stage, and inspection of pretrial detention facilities by independent experts.84 Such reforms can have a significant impact on the health of prison populations, arguably even more significant than allowing access to condoms, sterile syringes, or opiate substitution treatment because they address both the worst forms of abuse and some of the root causes of adverse health trends within the criminal justice system.85
TOWARD A RESEARCH AGENDA ON HEALTH AND HUMAN RIGHTS OF DRUG USERS
Recent years have seen leading medical journals86 and UN officials, such as the UN High Commissioner for Human Rights and the Executive Director of the UN Office on Drugs and Crime,87,88 support the importance of protecting the human rights of people who use drugs. The programmatic features of an “enabling environment” for HIV prevention and treatment for IDU, however, have yet to be identified and evaluated. Implementers of programs for IDU have observed that the integration of legal aid and harm reduction can deter police from conducting surveillance nearby, giving providers the space needed to treat drug users with respect and ensure access to health services.89 Legal aid at the pretrial stage may help to persuade a judge not to detain a criminal defendant, thus averting the harmful effects of incarceration. Unfortunately, there are few evaluations of these commonsense observations or of the pathways by which they may lead to improved health outcomes for IDU.
Evaluative studies are also needed on whether the risk environment for people who use drugs and have HIV improves as a result of changes by law enforcement and health officials. Various tools, including police training, protocols, complaint mechanisms, and anticorruption measures have been used to change law enforcement practices that deter drug users from seeking health services, but their precise public health benefits, if any, remain unknown. Similarly, an extensive literature documents the effects of individual-level barriers to and support for adherence by IDU, but few metrics are available to measure systemic barriers that decrease ART adherence by people who use drugs or the efficacy of systemic remedies.30,46 Policies that prohibit active drug users from receiving ART, that require collateral fees and paperwork before treatment initiation, or that demand that IDU abstain from illicit drugs or enroll in substitution treatment before receiving tuberculosis treatment or ART are unethical and likely lead to “treatment failure.”
Given the impact of pretrial and arbitrary detention on health, structural interventions are needed to enhance protections in police lockups and to reform pretrial justice systems. Pretrial justice programs in Russia, Mexico, and Nigeria currently seek to reduce the numbers of persons detained, yet these same countries disproportionately detain IDU at risk for HIV. The goals and outcomes of these pretrial justice programs need evaluation, particularly regarding their effects on HIV acquisition and progression, HIV treatment, and treatment for drug dependence.
Reforming laws that authorize police surveillance and pretrial detention of drug users, particularly laws that criminalize so-called “internal possession” or positive urine tests and the possession of sterile injection paraphernalia, will likely be among the most powerful levers for structural reduction of HIV risk. UN Secretary General Ban Ki Moon has highlighted the need for removal of criminal penalties on people who use drugs and other groups vulnerable to HIV.90 The Executive Director of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, an HIV researcher and physician with over 500 peer-reviewed publications, has called for removal of penalties for personal drug possession.91 Portugal decriminalized possession of all drugs in 2001 and has subsequently reported increases in numbers of persons seeking drug-dependence treatment, decreases in HIV related to drug use and decreases in heroin use and heroin-related deaths.92 Its experiences demonstrate the importance of examining the public health effects of drug penalty reform. Studies are also needed of other law reforms, including those related to prostitution, sodomy, and intentional HIV transmission, to understand their impacts on access and use of health services and on the incidence and prevalence of HIV/AIDS and other infectious diseases.
The Joint United Nations Program on HIV/AIDS (UNAIDS) has proposed a package of interventions to remove legal and policy impediments to effective HIV prevention policies, including legal aid and empowerment for populations at risk, legal reforms, “know your rights” campaigns, training for service providers, programs to reduce violence against women and girls, and programs to reduce stigma and discrimination.93 A 2009 UNAIDS survey of 56 countries, however, reveals the challenge of moving from rhetorical commitments to implementation of programs that safeguard human rights. Although 85% of national strategic plans on AIDS mentioned stigma and discrimination or human rights concerns, few included specifics: nearly 7 in 10 made no mention of populations at risk, including IDU, sex workers, or men who have sex with men, or any programs to address human rights violations against them.93
Given the scale of police abuses against and detention of IDU, national commitments to universal access to HIV prevention and treatment must recognize that drug users do not forfeit their entitlement to health services or human dignity. “Combination prevention” for HIV-frequently cited as the best hope for containing the spread of HIV94,95-must be reconceptualized for criminalized populations to include such measures as legal aid, access to justice, and protection against police abuses. Without protection of these basic human rights, universal access for IDU is unlikely to change from a utopian ideal to anything approaching an achievable reality.
Special thanks to Joanne Csete, Thomas Kerr and his colleagues at the British Columbia Center for Excellence in Vancouver, and to Johna Hoey at the Open Society Foundations Public Health Program. Additional thanks to the National Institute on Drug Abuse (NIDA) of the National Institutes of Health, and to the International AIDS Society, for sponsoring a meeting on the Prevention and Treatment of HIV/AIDS among Drug Using Populations: A Global Perspective, in January 2010. Portions of this article were presented there, and benefitted from the insights of those in attendance.
1. Wolfe D, Sempruch MK. Seeing double: mapping contradictions in HIV prevention and illicit drug policy worldwide. In: Beyrer C, Pizer H, eds. Public Health and Human Rights: Evidence-Based Approaches
. Baltimore, MD: Johns Hopkins University Press; 2007:330-361.
2. Csete J, Cohen J. Lethal violations: human rights abuses faced by injection drug users in the era of HIV/AIDS. In: Malinowska Sempruch K, Gallagher S, eds. War on Drugs, HIV/AIDS and Human Rights
. New York, NY: International Debate Education Assocation; 2004:212-227.
3. Mathers BM, Degenhardt L, Phillips B, et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet
4. Institute of Medicine. Preventing HIV infection among injecting drug users in high-risk countries: an assessment of the evidence
. Washington, DC: National Academies Press; 2007.
5. Herget G. Methadone and buprenorphine added to the WHO list of essential medicines. HIV AIDS Policy Law Rev
6. Mocroft A, Madge S, Johnson AM, et al. A comparison of exposure groups in the EuroSIDA study: starting highly active antiretroviral therapy (HAART), response to HAART, and survival. J Acquir Immune Defic Syndr
7. Wood E, Hogg RS, Yip B, et al. Rates of antiretroviral resistance among HIV-infected patients with and without a history of injection drug use. AIDS
8. World Health Organization. HIV/AIDS treatment and care: clinical protocol for Injecting Drug Users. HIV/AIDS treatment and care: Clinical protocol for the WHO European Region
. Copenhagen, Denmark: WHO EURO; 2006.
9. Carrieri MP, Spire B. Harm reduction and control of HIV in IDUs in France. Lancet
10. Program Coordinating Board. Report of the Twenty-Fourth Meeting of the Programme Coordinating Board
. Geneva, Switzerland: UNAIDS; 2009.
11. Wood E, Kerr T, Marshall BD, et al. Longitudinal community plasma HIV-1 RNA concentrations and incidence of HIV-1 among injecting drug users: prospective cohort study. BMJ
12. Wolfe D. Paradoxes in antiretroviral treatment for injecting drug users: access, adherence and structural barriers in Asia and the former Soviet Union. Int J Drug Policy
13. Donoghoe MC, Bollerup AR, Lazarus JV, et al. Access to highly active antiretroviral therapy (HAART) for injecting drug users in the WHO European Region 2002-2004. Int J Drug Policy
14. Zhang F, Dou Z, Ma Y, et al. Five-year outcomes of the China National Free Antiretroviral Treatment Program. Ann Intern Med
. 2009;151:241-251, W-252.
15. Sharma M, Oppenheimer E, Saidel T, et al. A situation update on HIV epidemics among people who inject drugs and national responses in South-East Asia Region. AIDS
16. Ball AL. Universal access to HIV/AIDS treatment for injecting drug users: keeping the promise. Int J Drug Policy
17. Harm Reduction Developments 2005: Countries with Injection Driven Epidemics
. New York, NY: International Harm Reduction Development Program, Open Society Institute; 2006.
18. Struthers M, Csete J. Fanning the Flames: How Human Rights Abuses are Fueling the AIDS Epidemics in Kazakhstan
. New York, NY: Human Rights Watch; 2003.
19. Wolfe D, Saucier R. At What Cost? HIV and Human Rights Consequences of the Global “War on Drugs”
. New York, NY: Open Society Institute; 2009.
20. Wolfe D, Saucier R. In Rehabilitation's name: ending institutionalised cruelty and degrading treatment of people who use drugs. Int J Drug Policy
21. Csete J, Cohen J. Human rights in Vancouver: do injection drug users have a friend in city hall? Can HIV AIDS Policy Law Rev
. 2003;8:1, 7-10.
22. Human Rights Watch. Injecting Reason: Human Rights and HIV Prevention for Injecting Drug Users
. New York, NY: Human Rights Watch; 2003.
23. Schleifer R. Rhetoric and Risk: Human Rights Abuses Impeding Ukraine's Fight Against HIV/AIDS
. Human Rights Watch. 2006;18(2):1-88.
24. Maru V. Ravaging the Vulnerable: Abuses Against Persons at High Risk of HIV Infection in Bangladesh
. Vol. 15. New York: Human Rights Watch; 2003:6(C).
25. Human Rights Watch. Lessons Not Learned: Human Rights Abuses and HIV/AIDS in the Russian Federation
. New York, NY: Human Rights Watch; 2004.
26. Davis SL, Triwahyuono A, Alexander R. Survey of abuses against injecting drug users in Indonesia. Harm Reduct J
27. Hammett TM, Wu Z, Duc TT, et al. ‘Social evils' and harm reduction: the evolving policy environment for human immunodeficiency virus prevention among injection drug users in China and Vietnam. Addiction
28. Umar S. Break you down to build you up: the Malaysian experience. Paper presented at: 20th Conference on the Reduction of Drug-Related Harm; April 2009; Bangkok, Thailand.
29. Rhodes T, Singer M, Bourgois P, et al. The social structural production of HIV risk among injecting drug users. Soc Sci Med
30. Krusi A, Wood E, Montaner J, et al. Social and structural determinants of HAART access and adherence among injection drug users. Int J Drug Policy
31. Strathdee SA, Patrick DM, Archibald CP, et al. Social determinants predict needle-sharing behaviour among injection drug users in Vancouver, Canada. Addiction
32. Burris S, Blankenship KM, Donoghoe M, et al. Addressing the “risk environment” for injection drug users: the mysterious case of the missing cop. Milbank Q
33. Strathdee S, Hallett T, Bobrova N, et al. HIV and the risk environment among people who inject drugs: past, present, and projections for the future. Lancet
. 2010; In Press.
34. Hayashi K, Milloy M, Fairbairn N, et al. Incarceration experiences among a community - recruited sample of injection drug users in Bangkok, Thailand. BMC Public Health
35. Fairbairn N, Hayashi K, Kaplan K, et al. Evidence Planting by Thai Police Violates the Human Rights of People who Inject Drugs
. BMC International Health and Human Rights: Vancouver/Bangkok; 2009.
36. Sarang A, Rhodes T, Sheon N, et al. Policing drug users in Russia: risk, fear, and structural violence. Subst Use Misuse
37. Werb D, Kerr T, Small W, et al. HIV risks associated with incarceration among injection drug users: implications for prison-based public health strategies. J Public Health (Oxf)
38. Epperson M. A longitudinal study of incarceration and HIV risk among methadone maintained men and their primary female partners. AIDS Behav
. 2010. DOI: 10.1007/s10461-009-9660-9
39. Trostle J. Medical compliance as an ideology. Soc Sci Med
40. Escaffre N, Morin M, Bouhnik AD, et al. Injecting drug users' adherence to HIV antiretroviral treatments: physicians' beliefs. AIDS Care
41. Barriers to Access: Medication-Assisted Treatment and Injection-Driven HIV Epidemics
. New York, NY: International Harm Reduction Development Program, Open Society Institute; 2008.
42. Rhodes T, Platt L, Sarang A, et al. Street policing, injecting drug use and harm reduction in a Russian city: a qualitative study of police perspectives. J Urban Health
43. Shields A. The Effects of Drug User Registration Laws on People's Rights and Health: Key Findings From Russia, Georgia, and Ukraine
. International Harm Reduction Development Program, Open Society Institute; 2009.
44. Sarang A, Stuikyte R, Bykov R. Implementation of harm reduction in Central and Eastern Europe and Central Asia. Int J Drug Policy
45. Bobrova N, Sarang A, Stuikyte R, et al. Obstacles in provision of anti-retroviral treatment to drug users in Central and Eastern Europe and Central Asia: a regional overview. Int J Drug Policy
46. Wolfe D, Carrieri P, Shepard D, et al. Treatment and care for HIV-infected injecting drug users: a review of barriers and way forward. Lancet
47. Martin JP. 25+ Human Rights Documents
. New York, NY: Columbia University Center for the Study of Human Rights; 2001.
48. International Harm Reduction Association and Human Rights Watch. Recalibrating the Regime: The Need for a Human Rights-Based Approach to International Drug Policy
. London, United Kingdom: International Harm Reduction Association and Human Rights Watch; 2008.
49. Cohen J, Wolfe D. Harm reduction and human rights: finding common cause. AIDS
. 2008;22(Suppl 2):S93-S94.
50. Csete J, Elliott R, Kerr T, et al. Harm reduction, HIV/AIDS, and the human rights challenge to global drug control policy. Health Hum Rights
51. Altice FL, Mostashari F, Friedland GH. Trust and the acceptance of and adherence to antiretroviral therapy. J Acquir Immune Defic Syndr
52. Newman C. Establishing and maintaining a therapeutic alliance with substance abuse patients: a cognitve therapy approach. In: Lisa Simon Onken, Jack D. Blaine, John J. Boren. Beyond the Therapeutic Alliance: Keeping the Drug-Dependent Individual in Treatment
. Rockville, MD: National Institute on Drug Abuse; 1994.
53. Shannon K, Rusch M, Shoveller J, et al. Mapping violence and policing as an environmental-structural barrier to health service and syringe availability among substance-using women in street-level sex work. Int J Drug Policy
54. Werb D, Wood E, Small W, et al. Effects of police confiscation of illicit drugs and syringes among injection drug users in Vancouver. Int J Drug Policy
55. Rhodes T, Mikhailova L, Sarang A, et al. Situational factors influencing drug injecting, risk reduction and syringe exchange in Togliatti City, Russian Federation: a qualitative study of micro risk environment. Soc Sci Med
56. Bobrova N, Rhodes T, Power R, et al. Barriers to accessing drug treatment in Russia: a qualitative study among injecting drug users in two cities. Drug Alcohol Depend
. 2006;82(Suppl 1):S57-S63.
57. Csete J, Elliott R. Scaling up HIV testing: human rights and hidden costs. HIV/AIDS Policy and Law Rev
58. Jürgens R. Increasing access to HIV testing and counselling while respecting human rights. The Law and Health Initiative, Open Society Institute
59. Patrick S, Forman S. Multilateralism and US Foreign Policy: Ambivalent Engagement
. London, United Kingdom: Lynne Rienner Publishers; 2002.
60. Neier A. Social and economic rights: a critique. Hum Rts Brief
61. Alston P, Robinson M. Human Rights and Development: Towards Mutual Reinforcement
. New York, NY: New York University Center for Human Rights; 2005.
62. Altice F, Mostashari F, Friedland GH. Trust and the acceptance of and adherence to antiretroviral therapy. J Acquir Immune Defic Syndr
63. Bunnell R, Ekwaru JP, Solberg P, et al. Changes in sexual behavior and risk of HIV transmission after antiretroviral therapy and prevention interventions in rural Uganda. AIDS
64. Kahn J. The cost-effectiveness of HIV prevention targeting: how much more bang for the buck? Am J Public Health
65. WHO, UNODC, UNAIDS. Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users
. Geneva, Switzerland: World Health Organization; 2009.
66. World Health Organization. WHO Framework for Global Monitoring and Reporting: Monitoring and Reporting on the Health Sector's Response Towards Universal Access to HIV/AIDS Treatment, Prevention, Care and Support,
2009-2010. Geneva, Switzerland: WHO; 2009.
67. Rhodes T. The ‘risk environment': a framework for understanding and reducing drug-related harm. Int J Drug Policy
68. Cohen J, Csete J. Not enough graves: the war on drugs, HIV/AIDS, and violations of human rights. Human Rights Watch
69. Ainsworth M, Beyrer C, Soucat A. AIDS and public policy: the lessons and challenges of “success” in Thailand. Health Policy
70. Sarang A, Rhodes T, Platt L, et al. Drug injecting and syringe use in the HIV risk environment of Russian penitentiary institutions: qualitative study. Addiction
71. Hammett TM, Harmon MP, Rhodes W. The burden of infectious disease among inmates of and releasees from US correctional facilities, 1997. Am J Public Health
72. Beyrer C, Jittiwutikarn J, Teokul W, et al. Drug use, increasing incarceration rates, and prison-associated HIV risks in Thailand. AIDS Behav
73. Des Jarlais DC, Perlis T, Arasteh K, et al. HIV incidence among injection drug users in New York City, 1990 to 2002: use of serologic test algorithm to assess expansion of HIV prevention services. Am J Public Health
75. United Nations General Assembly. International Covenant on Economic, Social, and Cultural Rights res 2200a (XXI)
. New York, NY: United Nations; December 16, 1966.
76. Walmsley R. World Prison Population List
. London, United Kingdom: International Centre for Prison Studies (ICPS); 2007.
77. Nowak M. Report of the Special Rapporteur on Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment
. United Nations. Document no. A/HRC/10/44; Geneva, Switzerland: 2009.
78. United Nations General Assembly. International Covenant on Civil and Political Rights Res 2200A (XXI)
. New York, NY: United Nations; 1966.
79. Lines R. The right to health of prisoners in international human rights law. Int J Prisoner Health
80. Khudobin V. Russia. 59696/00
. Strasbourg, France: The European Court of Human Rights (Third Section); 2007.
81. Yakovenko V. Ukraine. 15825/06
. Strasbourg, France: The European Court of Human Rights (Fifth Section); 2008.
82. Ghavtadze V. Georgia. 23204/07
. Strasbourg, France: The European Court of Human Rights (Second Section); 2009.
83. Standard Minimum Rules for the Treatment of Prisoners. Res. 663 C (XXIV)
: UN ECOSOC; Geneva, Switzerland. July 1957.
84. The Global Campaign for Pretrial Justice. Pretrial Detention and Public Health: Unintended Consequences, Deadly Results
. New York, NY: Open Society Institute; 2010.
85. Epstein H. Claiming the Right to Health. Lancet
86. Jurgens R, Csete J, Amon J. Human rights and effects on HIV prevention and treatment (TBD). Lancet
87. Costa A. Keynote address. Presented at: 19th International Conference on the Reduction of Drug Related Harm; Warsaw, Poland; May 11, 2008.
88. Pillay N. High Commissioner Calls for Focus on Human Rights and Harm Reduction in International Drug Policy
. Geneva Switzerland: United Nations Press Release; March 10, 2009.
89. Carey C, Tolopilo A. Tipping the Balance: Why Legal Services Are Essential to Health Care for Drug Users in Ukraine
. New York: Open Society Institute, Public Health Program; 2008.
90. Ki Moon B. Progress made in the implementation of the Declaration of Commitment on HIV/AIDS and the Political Declaration on HIV/AIDS. Paper presented at: United Nations General Assembly; 2008; New York, NY.
91. O'Hara M. Curb AIDS and HIV by decriminalising drugs, say experts. The Observer
. April 19, 2009.
92. Hughes C, Stevens A. Briefing Paper Fourteen: The Effects of Decriminalization of Drug Use in Portugal Publisher: The Beckley Foundation Drug Policy Programme; 2007. pp. 1-10.
93. UNAIDS. Addressing Human Rights Issues in National Responses to HIV: A Review of Programmes to Reduce Stigma and Discrimination and Increase Access to Justice
. Geneva, Switzerland: United Nations; 2009.
94. Piot P, Bartos M, Larson H, et al. Coming to terms with complexity: a call to action for HIV prevention. Lancet
95. Merson M, O'Malley J, Serwadda D, et al. The history and challenge of HIV prevention. Lancet