Globally, the HIV epidemic has affected several distinct risk groups and populations disproportionately, highlighting well-described vulnerabilities to infection among men who have sex with men, sex workers and people who inject drugs. Studies have also identified that, within these risk groups, some ethnic minorities have elevated rates of HIV infection. In this issue of Addiction, Des Jarlais and colleagues reviewed studies to assess for racial/ethnic minority disparities in HIV infection among individuals who inject drugs . Their meta-analysis demonstrated a greater than twofold elevation in HIV prevalence among ethnic minority groups.
These findings lead inevitably to the question: why? In a study of intravenous drug users in Vancouver, we found that Aboriginal drug users had a higher baseline HIV prevalence upon recruitment into a prospective cohort study (16 versus 25%, P < 0.001) and that, among those participants who were HIV-negative at baseline, the cumulative HIV incidence at 48 months was higher among Aboriginal individuals (18.5 versus 9.5%; P < 0.001) . Beyond the very concerning public health implications of this study, what was interesting about this analysis was that the elevated HIV incidence among Aboriginal individuals persisted after adjustment for traditional HIV risk behaviours, such as syringe sharing and unsafe sex. Subsequent research has implied that elevated rates of incarceration as well as lower access to HIV and addiction treatment probably explain these findings .
In this context, the role that drug policies can play in contributing to the HIV epidemic and other harms among illicit drug users has recently been the subject of increasing international attention, including a recent report of the blue ribbon Global Commission on Drug Policy entitled The War on Drugs and HIV/AIDS: How the Criminalization of Drug Use Fuels the Global Pandemic . This report describes the range of ways in which the criminalization of drug-using individuals contributes to the spread of HIV infection. These mechanisms include behavioural influences created by the fear of arrest, restrictions on clean needle distribution and opioid substitution therapy, barriers to antiretroviral therapy and addiction treatment, as well as the negative influences of incarceration (Table 1).
The negative influences of incarceration were documented in the classic Scottish prison HIV outbreak investigation, which used phylogenetic techniques to demonstrate how HIV was spreading through syringe sharing among inmates . Prisons also have a negative effect on HIV ‘treatment as prevention’ strategies, which seek to use antiretroviral therapy to lower plasma HIV–response effect of incarceration events on antiretroviral non-adherence , and a Baltimore study of HIV-infected patients found recently that even brief periods of incarceration were associated with a twofold risk of syringe sharing and a greater than sevenfold risk of HIV virological failure .
As indicated in the Des Jarlais paper , ethnic disparities in HIV infection are particularly large in the United States, where the nation's long-standing ‘war on drugs’ has had a decidedly negative impact on minority communities. For instance, in the United States, African Americans are many times more likely to be incarcerated for drug-related offences than whites, despite the fact that African Americans and whites use drugs at similar rates. In this context, past research has suggested that disproportionate incarceration rates are one of the key reasons for the markedly elevated rates of HIV infection among African Americans . This is an urgent public health concern, as African Americans represent just 12% of the US population but, in recent years, have accounted for more than 50% of the nation's new HIV infections .
These observations raise questions about the role of the addiction medicine community in advocating for evidence-based reform of illicit drug policies. Many of us recognize the ineffectiveness of the war on drugs and its disproportionate harmful impacts on minority communities, but the field of addiction medicine's response has arguably been largely muted, especially in the face of substantial social and health-related harms to our patients. This is illustrated by the 2012 document of the American Society of Addiction Medicine (ASAM) entitled ‘State-level proposals to legalize marijuana’ . This report argues forcefully against state proposals to reform marijuana laws, stating: ‘No modification of these proposals would make them acceptable’.
While the ASAM advocacy document acknowledges that arrests for marijuana possession account for 45.8% of US drug-related arrests, rather than acknowledging the health and social harms that can accrue from an individual's involvement in the criminal justice system, the report highlights instead the ‘significant role the criminal justice system plays in reducing marijuana use’ . Unfortunately, from an evidence-based public policy perspective, this conclusion is inconsistent with the World Health Organization's World Mental Health Survey Initiative, which looked recently at patterns of drug law enforcement and rates of drug use internationally and concluded that ‘globally, drug use is not distributed evenly and is not simply related to drug policy, since countries with stringent user-level illegal drug policies did not have lower levels of use than countries with liberal ones’ [5, 7]. Although the ASAM document's opposition to recent marijuana law reform proposals is based on the prevailing belief that marijuana availability will increase, research funded by the US National Institute on Drug Abuse has concluded that despite 30 years of marijuana prohibition, the drug already remains ‘almost universally available to American 12th graders’, with between 80 and 90% reporting consistently that the drug is ‘very easy’ or ‘fairly easy’ to obtain . The ASAM report's supportive conclusions regarding the role the criminal justice system plays in reducing marijuana use is also problematic in light of recent US research demonstrating that paternal incarceration is a strong predictor of subsequent adolescent drug use . These observations suggest that ASAM's efforts to improve addiction policy might have a more positive real-world impact if they gave serious consideration to the limitations and serious proven harms of the status quo alongside identifying hypothetical concerns with reform proposals.
In this context, one of the most intriguing discussions now taking place involves questioning whether the wealth of evidence regarding the regulatory approaches to controlling alcohol and tobacco use have relevance to illegal drugs . We may learn one day that strictly controlled legal regulation of drugs such as marijuana may help to eliminate the negative impacts of criminalization [1, 14] while limiting the potential negative effects of increasing availability .
In the context of the obvious failure and harms of the ‘war on drugs’ approach [1, 14], which include elevated rates of incarceration and HIV infection among ethnic minority groups, there is a clear need for the addiction medicine community to promote more actively an unbiased discussion regarding the possible policy alternatives—which are not simply limited to prohibition versus unrestrained legalization . Indeed, for drugs most relevant to the spread of HIV, reductions in rates of drug use have been attributed to carefully considered, progressive public health and regulatory approaches that have sought an evidence-based middle ground between these two extremes .
Declarations of interest