FUELING AN EPIDEMIC: HIV/AIDS, INJECTION DRUG USERS AND HUMAN RIGHTS
Joanne Csete, Human Rights Watch

Sometimes when public health officials issue yet another pronouncement on the global HIV/AIDS problem, there is a great collective glazing over of the world's eyes, but we saw in the last few weeks that when intelligence agencies talk about AIDS as a security issue, people listen. Last month, as Mr. van Lanschott said, a research body that is part of the U.S. Central Intelligence Agency released a report called "The Next Wave of HIV/AIDS" that drew a great deal of attention in the international press. In this report, it is projected that in five countries - Russia, China, India, Nigeria and Ethiopia - there will be up to 75 million people living with HIV/AIDS in eight years (2010). These are much higher figures than the United Nations has projected, and that's only five countries, so we're talking then about more than 120 million people living with the disease globally, according to this projection. The message is that this level of disease and death will destabilize these countries and their regions and that a warning is needed because, in the delicate phrasing of the report, these countries "have yet to demonstrate a sustained commitment" to managing HIV/AIDS. I can't think of a major international media outlet that didn't cover this report at length; it struck a nerve.

I would like for us to hear the language this report uses to describe HIV/AIDS in the Russian Federation, which was taken in some press reports to apply to Central Asia as well. It says: "Intravenous drug use drives the spread of the disease in Russia. … Experts warn that drug use is so widespread in Russia that many users are integrated into society with jobs and families, suggesting the disease is moving into the mainstream. Prostitutes and prison inmates - many of whom are intravenous drug users - are contributing to the spread of the disease….Russia's frequent use of prison amnesty programs that release infected inmates will worsen the HIV/AIDS epidemic among the general population unless accompanied by prevention and treatment programs" (emphasis added).

This is the CIA, and we shouldn't expect a lot of nuance about such things as human rights in this story, but I wonder what the effect would have been if this widely cited report had told the story a different way - if it had instead said:

"Injecting drug use is widespread, and the marginalization, criminalization and severe discrimination faced by drug users drive the spread of the epidemic. A level of social and political disdain among 'mainstream' persons (and even sometimes in AIDS education messages) nourishes a 'we/they' separation between drug users and 'respectable society,' and this stigmatization inevitably contributes to the spread of the disease beyond the drug using community. Women in prostitution and other sex workers, who are regularly marginalized and often criminalized, as a result find themselves frequently in situations where they cannot demand condom use of their clients, and they are frequently victims of sexual violence, including at the hands of the police. It is impossible in these circumstances for them to practice safe sex. Many prison inmates have faced abuse of their rights in the course of their arrest, detention and often their trials. In prison, they are devoid of rights. They are often unprotected from the dangers of drug use, unsafe sex, and sexual violence. It is no wonder many are HIV-positive and many infected in prison."

By this, I mean only to emphasize what we all know - that HIV/AIDS came into the world and maintains its horrible destruction around the world riding on the back of a wide range of human rights abuses. From even the most cursory reading of the history of HIV/AIDS, it is very clear that abusing the human rights of persons at high risk of infection and of persons living with AIDS is one of the most reliable ways to fuel this epidemic - and, conversely, protecting their rights yields great success. This was the visionary and consistent message of the late Jonathan Mann, the first director of the World Health Organization's Global Programme on AIDS, the forerunner to UNAIDS - this happy coincidence of good public health practice and good human rights protection. Where has this idea gone? In spite of the clarity of this lesson from history, it remains somehow a persistently difficult lesson to learn or anyway to put into practice. One place it never seems to show up is in budgets of AIDS programs and projects, as though one can reduce stigma and discrimination at no cost.

This idea is frequently mentioned in a superficial way, and even the CIA report has a section called "Social stigma," though to me "social stigma" sounds like not being invited to a party with all the popular people. In the phrase "stigma and discrimination" - which falls easily off the tongue and is the theme of the UN's World AIDS Days for the next two years - we have to hear the depths of a discrimination that drives violence, police harassment, and subordinate status in every way.

We have to understand by this term a stigmatization of drug users that is severe enough to drive a fear so deep that people don't even dare to show up to take advantage of services that could save their lives. We have to understand as part of this picture of stigma and discrimination:

• That drug use continues to be the domain of laws that by their very terms violate the human rights of users.
• That drug users continue to be subject to arbitrary arrest, continue to be the easiest targets when the police are looking for someone on whom to pin false charges, and continue to face police harassment even when doing socially helpful things like seeking clean needles (if they are in the small minority with access to such services).
• That mandatory HIV testing is faced by drug users in too many situations with no possibility of confidentiality around their test results.

In these circumstances, and with the degree of demoralization, despair and even fatalism that results from a life of abuse, why would anyone be motivated even to try to protect him or herself from HIV, let alone to be part of a larger fight against AIDS?

I am afraid that HIV/AIDS in Central Asia has thrived so far in large part because it is so easy to say "oh, those are just drug users - who cares?", as in India it has been so easy for a ruling political party defined by moral judgmentalism and religious fundamentalism to say "oh, those are just prostitutes" and as it has been easy for the world to say, while 20 million died, "oh , those are just Africans." Twenty million Africans dead, and no one quite accountable. If the Central Asian countries allow such cavalier disdain and dismissal to continue, then they are surely on their way to a calamity of mortality and destruction in every sphere of life that is unimaginable, and they will surely lose the people who would have been the best allies governments have in this struggle.

I do not wish to overstate the case. It is more than human rights violations that drive HIV/AIDS in Central Asia and more than respect for human rights that will be neeeded to contain and ulimately defeat it. We know that poverty, lack of economic opportunity, declining education and health systems, and so on all play a role. And the many factors that drive the narcotic drug trade, including official corruption, will persist. But it is no exaggeration to say - and the track record is clear from many countries - that consistent discrimination against and abuse of those at high risk and those living with HIV/AIDS at the very least accelerate significantly the epidemic's progression, including its progression from a disease "contained" among high-risk populations to one in the general population.

And we know, moreover, that all those same other factors - poverty, declining social services, etc. - make it harder to make the case for respecting the rights of drug users and sex workers. It was said to us several times in Kazakhstan in the work we did there in August - how can we make the case for harm reduction services for drug users (and, even more difficult, for antiretroviral drugs for IDUs) when the general population has to struggle to get basic heatlh care? It's a good question. I think it should be sufficient to answer that questions with a human rights argument but, practically, it is not. In this regard, I would only emphasize that AIDS is not just one more health problem. I am mindful of the far too numerous funerals of young adults, friends and colleagues, that I attended during the years I lived in Africa when I say that if governments in this region do not commit themselves to the fight against AIDS at this key moment with vastly more resources and engagement than we have seen so far, the deterioration in social services that the region has seen in the last fifteen years will seem like nothing compared to what will transpire.

It is not easy, but we must be able - as a first step, at least - to imagine that it is possible through policy and law, and some practical attention to implementation of policies and laws, to go a long way to undoing the demonization of drug users, sex workers, MSM and persons with AIDS and that this transformation is meaningful for prevention in some quantifiable way.

We have to be able to imagine that it is possible that drug users can enjoy the full benefits of due process and equality before the law without society falling apart. We have to be able to imagine that people with AIDS can live openly, can get up every morning without fearing censure from society, abandonment and scorn from their families, and horrible indifference from those who should be working respectfully with them to design services and information for them. We have to imagine a day when those few people who now do the work of bringing dignity to the lives of people with AIDS don't have to spend every waking hour fighting for the most minimal necessities of life for a marginalized and disempowered population but rather where people with AIDS will be valued as among the most effective educators - which they surely are - and generally essential allies in the struggle against the epidemic.

The challenge of finding the courage to build a culture of rights for injecting drug users and people with AIDS is, of course, not unique to Central Asia. And some of the policies and practices in countries that have been dealing with AIDS for a long time are very poor models. The US clings to the ruins of a failed drug war which has no shortage of consequences around the world. The model of the Netherlands, with its strong focus on the rights of drug users, is such a rare one.

Human Rights Watch recently had the honor with others of giving an award for HIV/AIDS and human rights action to an organization in Canada called VANDU, the Vancouver Area Network of Drug Users, a truly remarkable group of users, which was born of the challenge of perhaps the worst AIDS epidemic in North America in a marginalized and crime-ridden part of the city of Vancouver. VANDU is a force in public policy debates and has truly changed the way in which drug users are perceived in the community. At the award ceremony, we were reminded that in the late 1990s there was a time when from this small ten-block-square area of Vancouver, there were over 400 deaths a year of drug users from AIDS or from overdose. It happened during this time that four "respectable" men with respectable families living "normal" lives in the suburbs went into the city and scored what they thought was cocaine, but it turned out to be heroin cut with some toxic substance, and all four men died. The media coverage of the deaths of the four respectable men included the commentary that these deaths were a particular loss to the community because these men "were not just junkies." Not just junkies. As though if they were "just junkies," the deaths would not have been worth mentioning.

It is not just early-in-the-meeting cheerleading to say that the Central Asia countries have an opportunity - of very limited duration - to do all of this better than countries have managed to do in other parts of the world, not just avoiding the poisonous discrimination, persecution and repression of persons at risk, but providing real global leadership on better programs and policies.

Please don't let this be a drama that features anywhere the line "those are just junkies." It is my sincere hope that this meeting will fire our imaginations and clarify our policy vision in helping us all to lead the region to feature respect for the rights of drug users and others affected by AIDS as a central part of Central Asia's successful fight against this terrible disease.