The giant blinks
American emphasis on abstinence-only approaches, long familiar from global debates over condoms and sex education, have recently extended to include HIV prevention efforts among injection drug users: at the March 2005 meeting of the Commission on Narcotic Drugs, for example, the first to focus on HIV prevention, U.S. representatives steadfastly insisted that any mention of needle exchange be removed from all resolutions. Washington representatives also deemed mention of the human rights of drug users unacceptable, and sought to replace mention of HIV prevention with references to treatment to stop substance abuse. Negotiations with the U.S., a Latin American delegate active in the meeting recalled later, were ”like taking a beating.“
That prologue made it all the more striking when advocates for evidence-based approaches to HIV prevention won an important victory in Geneva on June 29, when the U.S. endorsed a UNAIDS strategy for global HIV prevention that included mention of access to sterile injection equipment and the human rights of drug users. The group responsible for adopting the HIV prevention strategy, known as the UNAIDS Programme Coordinating Board, had split after U.S. officials insisted in preliminary meetings that all references to needle exchange be removed from the document. This time, though, a global coalition mobilized to resist American strong-arm tactics, mobilizing NGOs and seeking support from those UN member states where needle exchange has contained HIV infections.
In the United States, the only country in the world to mandate a ban on use of any federal funding for sterile injection equipment, HIV prevention, drug policy and human rights groups issued a sign-on letter, and a phone call campaign, urging U.S. Global AIDS Coordinator Randall Tobias not to allow ideology to trump the extensive scientific evidence in favor of clean needles. Advocates also rallied attention from sympathetic lawmakers and leading U.S. media: California congressman Henry Waxman sent a letter to U.S. Secretary of State Condoleezza Rice to emphasize the dangers of replacing science with ideology at UNAIDS, and a June 27th New York Times editorial referred to U.S. efforts to force a retreat from needle exchange ”a breathtakingly dangerous step.“ In Europe, HIV prevention experts briefed delegations from other member states to strengthen their commitment to standing up for science, and to underscore the dangers of allowing a frankly ideological approach to shape the global response to HIV.
These combined efforts paid off. In the final discussions at UNAIDS, the U.S. confronted virtually unanimous opposition. The Dutch proposed language about a comprehensive approach to HIV prevention that included sterile injection equipment, while Canada added the importance of ”respect for human rights of drug users.“ Delegates from Europe and Australia, where needle exchange has contained the HIV epidemic to a much greater extent than in the U.S., were particularly forceful in arguing against U.S. objections. Norway noted that it would be ”irresponsible“ not to base HIV prevention on the evidence, and Finland suggested that to remove mention of sterile injection equipment would be ”unethical.“ A compromise proposed by the UK, that would have included language about the right for donor nations to support only those interventions they chose, was rejected by other participants as unnecessary. Even Senegal, a country with few documented cases of HIV via injection, urged the UN to stick to the language in favor of harm reduction contained in the declaration of commitment adopted by all nations, including the U.S., at the 2001 UN General Assembly Special Session on HIV/AIDS. Confronted by a unified front in Geneva and growing criticism at home, U.S. officials withdrew their objections.
Words are not action: as numerous UN declarations demonstrate, there is a long distance between declaring commitment on paper and ensuring support for meaningful services on the ground. Donor governments can, and do, choose to support those initiatives that match their priorities, and to ignore those that are politically undesirable. Nonetheless, the UNAIDS document is meant to set the agenda for HIV prevention activities worldwide, and removal of language about needle exchange from the UN document would have sent the signal that needle exchange anywhere was unacceptable to the world’s largest supporter of AIDS relief. That message is particularly dangerous in Asia and the former Soviet Union, where many countries are facing injection-driven HIV epidemics and assessing whether clean needle programs are an appropriate way to respond. Viewed through that lens, U.S. endorsement of the UNAIDS document (available at www.unaids.org) offers clear recommendations in favor of sterile injection equipment and respect for human rights at a time when both are badly needed.
Daniel Wolfe, Deputy director of the International Harm Reduction Development Programme, Open Society Institute
EATN - European AIDS Treatment News, Volume 14, II – Autumn 2005
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