Government responses

Given the extent and gravity of the health consequences of the global injection drug use epidemic, public health approaches would argue for rapid and widespread implementation of preventive approaches with evidence of efficacy for both drug treatment and mitigation of the harms associated with drug use. That this kind of response has proven to be so difficult, and to have become a politicized and passionately debated issue in so many settings, is undoubtedly due (at least in part) to the social ambivalence toward substance use and attitudes toward users. Are addicts patients or criminals? Do they deserve compassion or punishment or disdain? Should we provide services to addicts to prevent spread of diseases to the "general population," however defined, or should we deny services and resources (including access to anti-viral therapies for HIV and HCV infection) to the "guilty," who have acquired their infections through high-risk behavior? There are governments and societies who have accepted the harm-reduction approach to substance use, and who have implemented widespread provision of services to drug users - examples include Australia, the Netherlands, the UK, Hong Kong, and Canada. And there are governments that continue to criminalize users, incarcerate addicts without treatment, and deny those with histories of injection drug use access to life-saving therapies. The latter list is unfortunately long, and includes states in the Americas, Europe, the former Soviet Union, Asia, and Africa. A critical question in attempting to understand the social ecology of this problem is the extent to which government responses can drive (and have driven) infectious disease spread among drug users. This takes us beyond the level of individual risks and into the more difficult realm of attribution of social or ecologic risks for transmission. And it is here, too, that we must ask whether human rights violations against drug users are understudied risk factors for disease acquisition and transmission.

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