Today Estonia has the fastest spread of HIV in the world, closely followed by several other countries in the former Soviet Union. The common factor of the spread in these countries as well as several Asian countries is that HIV mainly spreads among intravenous drug abusers.
The policy recommended by WHO and UNAIDS as a solution to this part of the problem can be summed up under the heading ”Harm reduction”. The strategy is based on the thought that before the HIV epidemic, it was correct to combat drug abuse unconditionally, but since the outbreak of this deadly epidemic among intravenous addicts, the fight against HIV must now come before the fight against drugs.
Harm reduction strategy consists of: exchange/distribution of clean syringes, information, and maintenance treatment with for example methadone or Buprenorfin (Subutex). HIV testing is mentioned in parts of the document, but does not have any high priority in this strategy. Police intervention against the addicts is advised against; indeed the criminalisation of drug abuse itself is considered a bad thing, and non-prosecution for personal use is recommended instead. The reason to this is the presumption that addicts would otherwise not dare to ask for clean syringes or seek help against their drug abuse for fear of being arrested by the police.

Will this strategy be successful? The Swedish experience speaks against it.
Let’s begin with HIV testing. The HIV epidemic broke out in Sweden in 1983, and when the testing started in 1985, almost half of the heroin addicts in Stockholm were already HIV infected. Various measures were taken, of which HIV testing and counselling together with tracing the infection sources were the common feature. Needle exchange was for various reasons rejected in Stockholm, but was launched in Lund and Malmö, where however the epidemic had not spread among the intravenous addicts to the extent it had in Stockholm. Information and education of both staff and addicts came quickly in operation among correctional treatment and addiction treatment facilities. Firstly, the addicts were advised against injecting, secondly: against sharing injecting tools, thirdly: to always boil the tools if someone else had used them before and so on. Furthermore, they were advised to always use condoms during sexual intercourse. A certain change of behaviour patterns could be noticed during the first years, although it was modest (ref. I). However, the epidemic was arrested, and the HIV prevalence today is some 5 % among the heroin addicts in Stockholm. What is the reason to this relative success? The addicts obviously continue to share needles in ”emergency situations” (the continuing spread of hepatitis C is a clear indication of this), but they try to avoid sharing needles with those they know to be HIV infected, and avoid unsafe sex with known HIV -positive partners. The prerequisite of this relatively successful strategy chosen by the addicts themselves is regular testing and openness among the addicts, which more or less has become a norm within the drug abuse ”culture” in Sweden. An important factor to that abusers did agree to testing was also that they had a relatively good access to medical care on their own terms (for example a special ward for infected drug addicts at Huddinge hospital and since some time ago non-institutional care at Meeting Point Maria.). The extended methadone treatment also plays a part, but it is important to point out that it still upholds the same strict line with rigorous conditions for abstinence, in contrast to the Harm reduction strategy, which recommends more unconditional methadone distribution. A great impact has also the fact that the correctional facilities do not discriminate HIV positive interns by placing them in special wards, which has made the testing more difficult for example in Great Britain.
Our experiences consequently indicate that testing and counselling in combination with opennes among the addicts about their HIV status within the group is most important, and that needle exchange/distribution is not necessary to curb the HIV epidemic within this group.
A recent study comparing the Nordic countries also supports this hypothesis. In Sweden and Norway, which have invested a lot in testing and counselling, the epidemic has markedly slowed down, while in Denmark, which didn’t take the same measures, the level of spread stays higher. Unlike Stockholm, both Norway and Denmark have had a generous distribution of needles and syringes. Consequently, needle exchange by itself does not seem to have any major impact. If this indeed is the case, it is very unfortunate that international organs put so little weight on testing and counselling, and instead recommend needle exchange as a first hand measure for this group. As a result, the poorest countries, for example Moldavia and Ukraine, cannot afford to HIV test all their drug addicts while it is very easy for them to get money from for instance the Soros Foundation for purchase of needles and syringes. To believe that access to clean needles and syringes makes HIV testing unnecessary is just as wrong as to believe that of condoms, which is a dearly-bought experience among the risk group of men having sex with men. Many studies clearly show that, learning that one is HIV infected, leads to increased responsibility. Our experience is that this is very much the case also among drug addicts.

Is it better then, not to have needle and syringe distribution at all? With no needle distribution, like in Stockholm, you evidently get a spontaneous black market for needles – often operated by drug dealers who also sell needles. One argument for needle distribution is that in connection with the distribution, HIV testing is offered, as well as other important health care measures like vaccination against hepatitis A and B, birth control counselling, dental care and so on. However, many of the needle distribution projects launched in the poor countries, totally lack these components (the Swedish proposition doesn’t include a demand to offer HIV testing either). The question is not whether to have needle exchange or HIV testing, but their order of priority. If you can afford it, you can offer the whole programme, but if you have limited resources, you should in my opinion give priority to testing and counselling. If you want to reach a large part of intravenous drug addicts, you should HIV test in jails and prisons, where a large part of this group regularly turns up.

Further to step two. Is it true that addicts don’t dare to seek help for fear of being arrested for drug consumption and possession of small amounts of drugs? Not according to our experiences. Not even the compulsory element in the Law on Infectious Disease Control has scared the addicts from HIV testing themselves, like many feared. Quite on the contrary, they support this law, and in some cases have even reported on each other, which is very unusual among criminals. Having sex with somebody without informing that you are HIV infected is namely not accepted among the addicts.

So what will happen with this part of the HIV epidemic if we don’t combat the drug abuse epidemic itself? That is exactly the question if we decriminalize drug abuse and abstain from prosecuting for possession for private consumption. In Sweden we managed to curb the spread of drug abuse in 1997 only after we criminalized drug consumption and established street level drug squads among the police. The spread of drugs can only be curbed through early intervention with clearly stated consequences to young people who experiment with drugs. Health measures become relevant much later and are of course necessary, but can never alone put a stop to the epidemic. Furthermore, co-operation with the police and the judicial authorities must not be ignored if a drug abuse epidemic is to be successfully combated.

If the drug abuse epidemic itself is not stopped, the number of people liable to get HIV infected through injection tools will constantly increase, apart from all the suffering and misery drug dependency causes to the individual, relatives and the society at large.

Those who recommend harm reduction as described above, even leading scientists and authorities within WHO and UNAIDS, are openly starting to advocate for legalising drugs, Cannabis in the first place, but also heroin. At the AIDS conference in Bangkok, a speaker at a seminar on HIV and intravenous drug abuse proposed legalisation of heroin and received loud applause. The justification once again was that arresting drug abusers would counteract harm reduction.

Consequently it appears that a movement with seemingly good intentions – harm reduction - by giving priority to needle and syringe distribution at the expense of HIV testing, stands in the way of not only an effective fight against HIV among intravenous addicts, but also the global fight against drugs.
Furthermore, it is my impression that this movement is highly organised, well funded and extremely powerful.

References:
1. Käll K I, Olin R.: HIV status and changes in risk behaviour among intravenous drug users in Stockholm 1987-1988. AIDS 1990, 4:153-157
2. Amundsen, E, Eskild et al.: Legal access to needles and syringes/needle Exchange programmes versus HIV counselling and testing to prevent transmission of HIV among intravenous drug users. A comparative study of Denmark, Norway and Sweden. European Journal of Public Health. Vol. 13, 2003: 252-258