Conflicting views within the UN system on harm reduction have become a major concern. Consistency in messages is crucial especially where it concerns joint global programmes such as the efforts to slow down the HIV/AIDS epidemic; efforts in which harm reduction practices like needle exchange and substitution treatment play a pivotal role. Longer existing tensions reached a new peak after a meeting between the Executive Director of the UN Office on Drugs and Crime (UNODC), Antonio Maria Costa, and US Assistant Secretary of State for International Narcotics and Law Enforcement Affairs (INL), Robert Charles, on November 10, 2004. At the meeting the US government - the biggest donor of UNODC - threatened Costa to cut funding to UNODC unless he assured that UNODC would abstain from any involvement in or expression of support for harm reduction, including needle exchange programmes. The next day, Mr Costa wrote a mea culpa letter to Mr Charles (1) making the required promises to secure continued US funding. "On the general issue of 'harm reduction', I share your concern. Under the guise of 'harm reduction', there are people working disingenuously to alter the world's opposition to drugs. These people can misuse our well-intentioned statements for their own agenda, and this we cannot allow. Accordingly, and as we discussed in our meeting, we are reviewing all our statements, both printed and electronic, and will be even more vigilant in the future." He made clear that UNODC maintains a strong opposition to heroin maintenance and drug injection rooms, which in his view run counter to the UN drug control conventions. On the issue of needle exchange, according to Costa, the linkages between injecting drug use and the HIV/AIDS pandemic fuel a controversy placing UNODC in a difficult position. "Nevertheless, and again taking our guidance from the conventions, CND and INCB, we neither endorse needle exchange as a solution for drug abuse, nor support public statements advocating such practices." This position taken by Mr Costa under US pressure is in direct conflict with many statements made by other UN agencies and statements made by UNODC representatives or in UNODC documents in the recent past. More than ever, inconsistency reigns within the UN around an issue all 191 UN Member States have pledged to achieve in the Millennium Development Goals: Halt and begin to reverse the spread of HIV/AIDS. The General Assembly Special Session in 2001 on HIV/AIDS adopted a Declaration of Commitment saying that "harm reduction efforts related to drug use," and "expanded access to essential commodities, including [...] sterile injecting equipment" should be ensured by 2005. (2) Both WHO and UNAIDS use the term harm reduction as a matter of course. "The United Nations fully endorses the fundamental principles of harm reduction," according to Catherine Hankins, associate director of UNAIDS in her opening address at the 13th International Conference on Drug Related Harm in Slovenia, 2002. (3) Legality of harm reduction under the UN drug Conventions The International Narcotics Control Board (INCB) has been regularly out of tune with the rest of the UN community on the issue of harm reduction. INCB president Philip Emafo, for example, considered in an interview even needle exchange to be contrary to the conventions and condemned the harm reduction policy trend as a "crusade" to undermine them. (4) UNODC legal experts, however, argued in a confidential and authoritative memorandum to the INCB in 2002, Flexibility of Treaty Provisions as Regards Harm Reduction Approaches that most harm reduction measures are in fact acceptable under the conventions. (5) According to the Legal Affairs Section "it could easily be argued that the Guiding Principles of Drug Demand Reduction provide a clear mandate for the institution of harm reduction policies that, respecting cultural and gender differences, provide for a more supportive environment for drug users." On methadone substitution treatment the UNODC experts say that it "could hardly be perceived as contrary to the text or the spirit of the treaties. It is a commonly accepted addiction treatment, with several advantages and few drawbacks. Although results are mixed and dependent on many factors, its implementation along sound medical practice guidelines would not constitute a breach of treaty provisions." On needle exchange the document says that this is a "rather straightforward strategy to reduce the risk of contagion with communicable diseases to IV [intravenous] drug abusers who share needles or syringes. It has been introduced in many countries around the world, to help reduce the rate of intravenous transmission of HIV and other transmittable diseases." About drug injection rooms, the legal advice given is that "even supplying a drug addict with the drug he depends on could be seen as a sort of rehabilitation and social reintegration, assuming that once his drug requirements are taken care of, he will not need to involve himself in criminal activities to finance his dependence" and that it "would be difficult to assert that, in establishing drug-injection rooms, it is the intent of Parties to actually incite to or induce the illicit use of drugs, or even more so, to associate with, aid, abet or facilitate the possession of drugs. [..] On the contrary, it seems clear that in such cases the intention of governments is to provide healthier conditions for IV drug abusers, thereby reducing their risk of infection with grave transmittable diseases and, at least in some cases, reaching out to them with counselling and other therapeutic options. Albeit how insufficient this may look from a demand reduction point of view, it would still fall far from the intent of committing an offence as foreseen in the 1988 Convention." Finally, addressing the remaining doubts about a potential tense legal footing of some treaty articles with harm reduction, the document states, referring to the HIV/AIDS crisis: "It could even be argued that the drug control treaties, as they stand, have been rendered out of synch with reality, since at the time they came into force they could not have possibly foreseen these new threats." UN consistency on harm reduction and HIV/AIDS prevention In 2004 the position of UNODC seemed to move towards closer harmony with other UN agencies, especially regarding the usefulness of harm reduction measures for the purpose of HIV/AIDS prevention. UNODC is co-sponsor of the Joint United Nations Programme on HIV/AIDS (UNAIDS), is the convening agency of the UNAIDS Inter-Agency Task Team (IATT) on injecting drug use and - since July 2004 for a one-year period - chair of the UNAIDS Committee of Co-sponsoring Organizations. In his Report to the Commission on Narcotic Drugs (CND) in Vienna last year, UNODC Executive Director Costa clarified the position of UNODC on the issue of harm reduction for HIV/AIDS prevention. (6) "Taking into account that drug use is a chronically relapsing condition, policies governing HIV/AIDS prevention must follow pragmatic approaches and therefore must address high-risk behaviour first before striving to achieve long-term goals such as total abstinence from drugs. Effective programmes typically include a wide variety of measures, ranging from drug dependence treatment, including drug substitution treatment, outreach providing injecting drug users with information on risk reduction and referral to services, clean needles and syringes, and condoms [..]. Thus, those injecting drug users who cannot stop injecting can be provided with clean needles and syringes, those who can stop injecting but who are not ready for abstinence-oriented treatment can be offered substitution treatment and a variety of treatment and rehabilitation options can be made available to those who have been able to stop using drugs. [..] A comprehensive package of measures also usually includes treatment instead of punishment for persons convicted of minor drug offences, since incarceration usually increases the risk of HIV transmission. The scientific evidence and the experience with such programmes strongly indicate that the above-described package is effective in reducing the risk of HIV transmission among injecting drug users and the risk of HIV diffusion from infected drug users to the general population." Mr Costa reiterated that position in his address to the Bangkok International AIDS conference in July 2004 (7): "During the past decade, we have also learned that the HIV/AIDS epidemic among injecting drug users can be stopped - and even reversed - if drug users are provided, at an early stage and on a large scale, with comprehensive services such as outreach, provision of clean injecting equipment and a variety of treatment modalities, including substitution treatment. [..] In too many countries, drug users are simply incarcerated. This is not a solution; in fact, it contributes to the rapid increase in the number of people living with HIV/AIDS." This shifting UNODC position towards the broader UN consensus on basic harm reduction practices forms the background to the current US pressure on the agency. The combination of two resolutions seeking CND acceptance for such a consensus at the March 2004 CND session, from Brazil on HIV/AIDS and the Pompidou Group on substitution treatment, and Costa's position paper on HIV/AIDS quoted above and one on substitution treatment by WHO/UNAIDS/UNODC was the prelude to the current crisis in US-UNODC relations. An angered US delegation made blunt statements during the session like that needle exchange programmes in fact might accelerate the spread of HIV instead of preventing it. Thereby denying the wisdom of their own top scientists. An analysis from the US Assistant Secretary for Health and Surgeon General, Dr David Satcher, on Evidence-Based Findings on the Efficacy of Syringe Exchange Programs (8) had concluded that, "After reviewing all of the research to date, the senior scientists of the Department and I have unanimously agreed that there is conclusive scientific evidence that syringe exchange programs, as part of a comprehensive HIV prevention strategy, are an effective public health intervention that reduces the transmission of HIV and does not encourage the use of illegal drugs." The Leadership Statement on Injecting drug use and HIV/AIDS (9), resulting from the XV International AIDS Conference in Bangkok in July 2004, confirmed the strong evidence base: "There is overwhelming, high quality evidence of very effective, safe and cost effective harm reduction strategies to reduce the negative health and social consequences of drug injection. [..] Experience of numerous programs and projects in all regions of the world indicate that HIV/AIDS epidemics among injecting drug users can be prevented, stabilized and even reversed by timely and vigorous harm reduction strategies." Meanwhile, harm reduction practices have been spreading over the planet, in Europe, in Canada, Australia, Brazil, Argentina, Uruguay, and China recently starting needle exchange programmes and announcing to open 1000 methadone substitution treatment clinics over the years to come, and countries like Iran, Pakistan and Vietnam talking openly about the need to introduce harm reduction. Losing tolerance with zero tolerance. A key moment will be the 48 th session of the Commission on Narcotic Drugs (CND) in Vienna, the principal drug policy-making body within the UN system. In the run-up to the CND (7-14 March 2005), an annual event usually passing by largely unnoticed by mainstream media and NGOs working on drugs and HIV/AIDS issues, this time many statements were made expressing concern about US efforts to force a UNODC retreat from support of syringe exchange and other harm reduction measures proven to contain the spread of HIV among drug users. In an open letter released on March 1, over 200 organizations - including TNI - and many individuals in 56 countries made an urgent appeal to CND delegates: "As you gather this year to debate HIV/AIDS prevention and drug abuse, we respectfully urge you to support syringe exchange, opiate substitution treatment and other harm reduction approaches demonstrated to reduce HIV risk; to affirm the human rights of drug users to health and health services; and to reject efforts to overrule science and tie the hands of those working on the front lines. No less than the future of the HIV epidemic is at stake." Leading medical journals joined the chorus. The Lancet stated in an editorial – ‘Losing tolerance with zero tolerance’ - that "zero-tolerance approaches to drug use have often created more harm to the user than the drug use they were intended to prevent." And the Canadian Medical Association Journal commented that the coming weeks will define whether "the member states of the United Nations can rise to the challenge of mitigating the negative health impacts of global drug control treaties or whether timidity in the face of ideological bullying will prevail." Opinion-leading newspapers condemned US pressure in their editorials in strong wordings. The New York Times on February 26 referred to "a triumph of ideology over science, logic and compassion" and called on the US to "call off their budding witch hunt" against needle exchange and refrain from further attacks at the upcoming CND meeting. If the Bush administration could not bring itself to overcome its twisted logic "it should at least allow the rest of the world to get on with saving millions of lives." The Washington Post one day later, under the title ‘Deadly Ignorance’, called on the US government "to end this bullying flat-earthism. It won't help President Bush’s current effort to relaunch his image among allies. And it's almost certain to kill people." The International Federation of Red Cross and Red Crescent Societies, made it very explicit in its Guidelines on harm reduction related to injecting drug use (10): "Forcing people who use drugs further underground and into situations where transmission of HIV/AIDS is more likely, and denying them access to life-saving treatment and prevention services is creating a public health disaster. This happens even though the evidence from scientific and medical research on best practices and cost benefit analyses is overwhelmingly in favour of harm reduction programming. This includes needle exchange, drug substitution treatment and condom distribution as part of the response to HIV/AIDS. The message is clear. It is time to be guided by the light of science, not by the darkness of ignorance and fear." Recommendations Governments have to stand up to defend harm reduction practices or the few good lessons learned in drug policy making and methods proven to contain the spread of HIV/AIDS might be in danger. Countries with long-standing experience with harm reduction practices and less vulnerable to US pressures - Europe, Canada and Australia - have a particular responsibility. The price for avoiding confrontation will be paid in Asia, Latin America and the former Soviet Union. Tensions in US-UNODC relations should be resolved by more sustainable funding mechanisms, not by bowing to Republican flat-earthism. It is time to be guided by the light of science, not by the darkness of ignorance and fear. References 1. Letter of 11 November 2004, at: www.colombo-plan.org/www/images/pubs/pdf/unodcnov2004.pdf [PDF document] 2. A/RES/S-26/2 Declaration of Commitment on HIV/AIDS, resolution adopted by the UN General Assembly, 2 August 2001 [PDF document]. 3. UNAIDS Address at the 13th International Conference on Drug Related Harm, 3 March 2002, by Catherine Hankins, Associate Director Strategic Information, UNAIDS [PDF document]. 4. Interview with Dr. Philip O. Emafo, ODCCP Update, December 2002. 5. E/INCB/2002/W.13/SS.5 Flexibility of treaty provisions as regards harm reduction approaches, prepared by the UNDCP Legal Affairs Section for 75th INCB session, 30 September 2002 [PDF document]. 6. E/CN.7/2004/3 Strengthening strategies regarding the prevention of HIV/AIDS in the context of drug abuse, report of the UNODC Executive Director for the 47 th session of the Commission on Narcotic Drugs, 12 January 2004 [PDF document]. 7. HIV/AIDS: Spread through Injecting Drug Use and in Prisons Needs to Be Addressed, UNIS/NAR/851, 12 July 2004. 8. Evidence-based findings on the efficacy of syringe exchange programs: an analysis of the scientific research com-pleted since April 1998, David Satcher, Assistant Secretary for Health and Surgeon General, 17 March 2000. 9. Leadership Statement on Injecting drug use and HIV/AIDS , XV International AIDS Conference in Bangkok in 11-16 July 2004 [PDF document]. 10. Spreading the light of science: Guidelines on harm reduction related to injecting drug use.