The Dual Stigmas of Injection Drug Use by Zhibin Dai

AIDS is most commonly conceived of as a sex-related disease. Most people who contract AIDS do so through sexual activity. This is particularly the case in sub-Saharan Africa, where the epidemic is most serious. But the AIDS epidemic is confined neither to the continent of Africa nor the act of unsafe sex. As the IFRC’s “Out of Harm’s Way” describes, injection drug use remains a major contributor to the spread of AIDS, particularly in Eastern Europe and Central Asia. The paper notes that three million injection drug users (IDUs) are currently living with HIV, and that social stigma against drug users significantly handicaps aid to this group, in terms of both the amount of funding available, as well as the willingness to engage in controversial harm reduction techniques such as needle exchange and drug substitution.

Our discussions about AIDS policy have often highlighted the tension between taking an ethically-upright approach to combating AIDS versus a more pragmatic, utility-focused view. This same tension appears to exist here as well, albeit with slight role reversals. In this case, the aid groups are the ones taking a more pragmatic approach, arguing that only focusing on reducing injection drug use is inefficient and that a sober view of the situation requires taking more realistic approaches, namely needle exchange and drug substitution. In contrast, many of the providers of global AIDS funding – including the United States – hesitate to support initiatives that many see as condoning drug abuse.

Personally, I don’t have a problem with the approach outlined by the IFRC. From the standpoint of reducing HIV transmission, using clean needles is certainly better than using unclean needles; getting drug users to switch from heroin to methadone, since the latter is not injection-based, is also better. As far as implementing this policy successfully, I think the IFRC’s work could benefit from two things: addressing the stigma problem and integration with broader anti-drug use policy.

In terms of stigma, harm reduction policy is hindered by two stigmas: stigma and public scorn for users and stigma against the approaches – needle exchange and drug substitution – to reduce HIV spread among this group. These two stigmas are obviously inter-related. You can imagine Joe Median Voter not being pleased about the government spending his tax dollars to buy syringes to give to drug users so that they don’t spread HIV. It’s probably not going to be effective to try and change public opinion about drug users because in this area, public opinion may be relatively hardened. It may be better to actually try and de-stigmatize needle exchange and possibly drug substitution because public opinion on these topics is not as well established (they are very much policy wonk concepts), and because advocates of these policies can emphasize their effectiveness in bringing down HIV infection rates among IDUs.

The second factor to maximizing the effectiveness of the IFRC’s harm reduction policies should be greater integration between it and broader anti- drug use policy. Ultimately, the goal of initiating programs directed at IDUs should be to reduce the number of people who inject drugs. That is a very difficult – and long-term – initiative, but we should nevertheless strive towards it. As such, I’d rather see harm reduction as a piece of this policy than a separate entity that is indifferent to this more ambitious goal. Incorporating harm reduction into policy aimed at reducing IDU can also improve the overall policy, most importantly by helping de-stigmatize the problem. Harm reduction policies focus on remaining non-judgmental and compassionate towards IDUs, and assuming this helps break down barriers and establishes trust between aid workers and IDUs, it should help lay a foundation for more proactive measures aimed at reducing injection drug use overall. It’s important to try and slow the number of people becoming IDUs every year because if that figure continues to grow, harm reduction will inevitably remain a damage limitation policy.

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