Criminal Justice Barriers to Treatment of Opioid Use Disorders in the United States: The Need for Public Health Advocacy.

Expanding access to treatment of opioid use disorder (OUD) is central to addressing the US overdose mortality crisis. Numerous barriers to OUD treatment are encountered in criminal justice institutions and processes, with which people with OUD are disproportionately involved. OUD treatment access is severely limited in US corrections facilities, with few exceptions. Drug treatment courts, which in principle provide court-supervised treatment as an alternative to prison, have also unduly limited treatment options, particularly medication-assisted treatment. The voice and expertise of health professionals are urgently needed to remove these barriers and ensure that criminally accused persons are systematically linked to the care they need.

Methadone treatment providers' views of drug court policy and practice: a case study of New York State.

BACKGROUND: Specialized drug treatment courts are a central part of drug-related policy and programs in the United States and increasingly outside the U.S. While in theory they offer treatment as a humane and pragmatic alternative to arrest and incarceration for certain categories of drug offenses, they may exclude some forms of treatment-notably methadone maintenance treatment (MMT). We sought to understand from the perspective of treatment providers whether this exclusion existed and was of public health importance in New York State as a case example of a state heavily committed to drug courts and with varying court-level policies on MMT. Drug courts have been extensively evaluated but not with respect to exclusion of MMT and not from the perspective of treatment providers. METHODS: Qualitative structured interviews of 15 providers of MMT and 4 NGO advocates in counties with diverse court policies on MMT, with content analysis. RESULTS: Courts in some counties require MMT patients to "taper off" methadone in an arbitrary period or require that methadone be a "bridge to abstinence". Treatment providers repeatedly noted that methadone treatment is stigmatized and poorly understood by some drug court personnel. Some MMT providers feared court practices were fueling non-medical use of prescription opiates. CONCLUSIONS: Drug court practices in some jurisdictions are a barrier to access to MMT and may constitute discrimination against persons in need of MMT. These practices should be changed, and drug courts should give high priority to ensuring that treatment decisions are made by or in close consultation with qualified health professionals.

People who use drugs, HIV, and human rights.

We reviewed evidence from more than 900 studies and reports on the link between human rights abuses experienced by people who use drugs and vulnerability to HIV infection and access to services. Published work documents widespread abuses of human rights, which increase vulnerability to HIV infection and negatively affect delivery of HIV programmes. These abuses include denial of harm-reduction services, discriminatory access to antiretroviral therapy, abusive law enforcement practices, and coercion in the guise of treatment for drug dependence. Protection of the human rights of people who use drugs therefore is important not only because their rights must be respected, protected, and fulfilled, but also because it is an essential precondition to improving the health of people who use drugs. Rights-based responses to HIV and drug use have had good outcomes where they have been implemented, and they should be replicated in other countries.

Vertical HIV transmission should be excluded from criminal prosecution.

Prevention of mother-to-child transmission of HIV (PMTCT) is an important part of global and national responses to HIV and AIDS. In recent years, many countries have adopted laws to criminalise HIV transmission and exposure. Many of these laws are broadly written and have provisions that enable criminal prosecution of vertical transmission in some circumstances. Even if prosecutions have not yet materialised, the use of these laws against HIV-positive pregnant women could compound the stigma already faced by them and have a chilling effect on women's utilisation of prevention of mother-to-child transmission programmes. Although criminal laws targeting HIV transmission have often been proposed and adopted with the intent of protecting women, such laws may disadvantage women instead. Criminal laws on HIV transmission and exposure should be reviewed and revised to ensure that vertical transmission is explicitly excluded as an object of criminal prosecution. Scaling up PMTCT services and ensuring that they are affordable, accessible, welcoming and of good quality is the most effective strategy for reducing vertical transmission of HIV and should be the primary strategy in all countries.

Male circumcision and HIV prevention: a human rights and public health challenge.

Three recent randomized clinical trials from Africa concluded that male circumcision can lead to a significant reduction in HIV risk for men. As a result, an exponential scale-up of services required to circumcise men is already figuring in the thinking of AIDS policy-makers at many levels. At this writing, the World Health Organization (WHO) is reviewing the three studies and other evidence, and is developing policy recommendations for making this HIV prevention intervention widely available. WHO says that this policy exercise"will need to take into account cultural and human rights considerations associated with promoting circumcision,"among other factors. In this article, Joanne Csete identifies some of the most important human rights questions that should be taken into account in the development of guidelines for national governments. The author argues that a scale-up of services to provide male circumcision provides an excellent opportunity to address issues concerning the subordination of women.

Seeing through the public health smoke-screen in drug policy.

In deliberations on drug policy in United Nations fora, a consensus has emerged that drug use and drug dependence should be treated primarily as public health concerns rather than as crimes. But what some member states mean by "public health approach" merits scrutiny. Some governments that espouse treating people who use drugs as "patients, not criminals" still subject them to prison-like detention in the name of drug-dependence treatment or otherwise do not take measures to provide scientifically sound treatment and humane social support to those who need them. Even drug treatment courts, which the U.S. and other countries hold up as examples of a public health approach to drug dependence, can serve rather to tighten the hold of the criminal justice sector on concerns that should be addressed in the health sector. The political popularity of demonisation of drugs and visibly repressive approaches is an obvious challenge to leadership for truly health-oriented drug control. This commentary offers some thoughts for judging whether a public health approach is worthy of the name and cautions drug policy reformers not to rely on facile commitments to health approaches that are largely rhetorical or that mask policies and activities not in keeping with good public health practise.

HIV, Sex Work, and Law Enforcement in China.

HIV prevalence in China is low in the general population but higher among certain key affected populations, including sex workers. Providing and purchasing sexual services are administrative offenses. Police engage in humiliating and repressive practices against sex workers. A study reported here based on the experience of over 500 sex workers highlights that the human rights abuses that sex workers face at the hands of the police directly undermine the country's HIV response toward sex workers. An important element of this phenomenon is the police's use of condoms as evidence of sex work, which impedes sex workers' possession and use of condoms. Whereas in some countries, sex worker collectives have helped empower sex workers to stand up to the police and safeguard their use of condoms, restrictions on civil society in China make such a strategy impossible. Removing sex work and related activities as offenses under the law in China, however politically difficult it might be, would ease this situation. Short of that, improving the coordination among and strategic harmony of public health and police roles and authorities would be useful.

How Drug Control Policy and Practice Undermine Access to Controlled Medicines.

Drug conventions serve as the cornerstone for domestic drug laws and impose a dual obligation upon states to prevent the misuse of controlled substances while ensuring their adequate availability for medical and scientific purposes. Despite the mandate that these obligations be enforced equally, the dominant paradigm enshrined in the drug conventions is an enforcement-heavy criminal justice response to controlled substances that prohibits and penalizes their misuse. Prioritizing restrictive control is to the detriment of ensuring adequate availability of and access to controlled medicines, thereby violating the rights of people who need them. This paper argues that the drug conventions' prioritization of criminal justice measures-including efforts to prevent non-medical use of controlled substances-undermines access to medicines and infringes upon the right to health and the right to enjoy the benefits of scientific progress. While the effects of criminalization under drug policy limit the right to health in multiple ways, we draw on research and documented examples to highlight the impact of drug control and criminalization on access to medicines. The prioritization and protection of human rights-specifically the right to health and the right to enjoy the benefits of scientific progress-are critical to rebalancing drug policy.

"Second on the needle": human rights of women who use drugs.

Women likely experience drug use in ways that are different than men, and may face discrimination based both on their status as drug users and their status as women. In this article, which is based on a presentation at a satellite session prior to the conference, Joanne Csete reviews existing data on women's use of drugs, and discusses the barriers in accessing health services faced by women who use drugs. The author concludes that there is an urgent need for rights-based, women-centered services for women who use drugs.

Harm reduction, HIV/AIDS, and the human rights challenge to global drug control policy.

The global HIV/AIDS pandemic, and the role of unsafe drug injection as one of its principal drivers, have added to the list of harms associated with unsafe drug use. HIV/AIDS has highlighted ways in which prohibitionist drug policy causes or contributes to such harms and focused attention on the international regime of illicit drug control. At the same time, HIV/AIDS has catalyzed the "health and human rights movement" to articulate legal and policy responses that both represent sound public health policy and fulfill human rights obligations recognized in international law; this necessarily includes scrutinizing the interpretation and implementation of the UN drug control conventions. This article brings together public health evidence and legal analysis as a contribution toward changing the global drug control regime to a more health-friendly, human rights-based system.

UN leadership and harm reduction: a rough road.

An unprecedented coalition of over 300 harm reduction, human rights and HIV/AIDS-focused NGOs from around the world worked together in support of harm reduction in the lead-up to the annual session of the UN Commission on Narcotic Drugs (CND) in March 2005.

Switzerland, HIV and the power of pragmatism: lessons for drug policy development.

Switzerland in the 1980s was an epicentre of HIV as open drug injection became part of the urban scene, especially in Zurich. Cracks appeared in Switzerland's long commitment to policing as the main drug-control strategy as law enforcement was unable to contain the health and social consequences of the rapid spread of drug injection. In the early stages of the epidemic, the pioneering health care providers who brought technically illegal harm reduction services into the open drug scene in Zurich helped open the exploration at the federal level of more balanced drug policy. Carefully evaluated pilot experiences in low-threshold methadone, needle exchange, and eventually heroin-assisted therapy yielded evidence of significant HIV prevention and crime reduction that was convincing not only to policy-makers but also to a skeptical Swiss public. Whilst not all countries have Switzerland's resource base, the Swiss experience still holds many useful lessons for establishing evidence-based policy on illicit drugs.

An inappropriate tool: criminal law and HIV in Asia.

BACKGROUND: Asian countries have applied criminal sanctions widely in areas directly relevant to national HIV programmes and policies, including criminalization of HIV transmission, sex work, homosexuality and drug injection. This criminalization may impede universal access to HIV prevention and treatment services in Asia and undermine vulnerable people's ability to be part of the HIV response. OBJECTIVE: To review the status of application of criminal law in key HIV-related areas in Asia and analyze its impact. METHODS: Review of literature and application of human rights norms to analysis of criminal law measures. RESULTS AND CONCLUSION: Criminal laws in the areas considered here and their enforcement, while intended to reduce HIV transmission, are inappropriate and counterproductive with respect to health and human rights. Governments should remove punitive laws that impede the HIV response and should ensure meaningful participation of people living with HIV, people who use illicit drugs, sex workers and men who have sex with men in combating stigma and discrimination and developing rights-centered approaches to HIV.