The recent backlash against the decriminalisation of drug use is a worrying sign of decision-makers’ short-sightedness. We, as a society, need to reconnect with marginalised people and not re-criminalise them.

Just four years after voters in Oregon approved Measure 110, a law that effectively decriminalised the use of illicit substances, legislators decided to change the law and re-criminalise drug use (

watch our interview with Theishia Naidoo, legal expert of the Drug Policy Alliance

). Furthermore, just one year after the Canadian province of British Columbia launched a 3-year experiment of decriminalising drug use, its government announced a few days ago that it will ban drug use in public spaces again.

In its 

, called decriminalisation “a qiuet revolution”, with a growing number of countries introducing various de facto and de jure alternatives to the criminalisation of drug use. Unfortunately, we cannot take the continuation of this trend for granted. We are now dangerously close to the point when re-criminalisation becomes a new trend, making the public see decriminalisation as a “failed experiment”. This will have a very harmful impact not only in the West but also in other parts of the world, where the proponents of much more repressive policies can use the “they tried it and it did not work” argument against reformers.

Decriminalisation has always been the result of decades-long advocacy efforts by professionals and activists, using arguments informed by both scientific evidence and lived experience. However, the arguments in favour of re-criminalisation are frustratingly shallow. The same old arguments for the war on drugs, which have never been backed up by evidence, are being reloaded and refurbished.

Proponents of re-criminalisation argue that, without a certain “nudge” from the criminal justice system, people who struggle with drug dependence will not be able to access treatment. However, if you look at research evidence on this issue, you will realise that coercion is not effective in boosting access to drug treatment. Furthermore, criminalisation leads to stigma, which is one of the most significant barriers to accessing services among people who use drugs. Police intervention may make people hide their drug use, but claiming that arrests are the only way to get people into treatment is nonsense. 

, the exact opposite is true: “criminalisation results in significant barriers to access to health services.”

Opponents of decriminalisation also argue that decriminalisation has not been successful in reducing drug use and related nuisances. They claim drug use is “out of control” after decriminalisation. This shows a fundamental misunderstanding of what decriminalisation is about. After decades of the war on drugs and its devastating effects on generations of marginalised communities, it is unfair to expect that simply removing criminal sanctions against drug users will magically solve all problems. Despite the decriminalisation of drug use, selling drugs remains illegal (they are out of control indeed, just like they have been before), with heavy consequences for public health and safety. Therefore, although decriminalisation has not led to increased drug use or overdoses, it also has not been able to reverse negative trends. The rise in overdose deaths correlates with a deadly drug toxicity crisis in North America. This crisis is dominated by extremely potent and toxic substances like fentanyl.

I believe that the single most important factor behind re-criminalisation is not a genuine concern for public health or the well-being of people who use drugs. Rather, the re-criminalisation efforts are spurred by the aesthetic concerns of upper- and middle-income people. It is not about social justice but about urban remodelling. It is no surprise that the campaign for re-criminalisation in Oregon was funded by 

 who think that the presence of marginalised people is bad for business. These businessmen realised that criminalisation of drug use would help the police get rid of these people. But people who think that re-criminalising drug use is a solution will be disappointed because the real problem is not drug use.

As a filmmaker, I had the privilege of visiting both Oregon and British Columbia in the past to document the drug situation (for instance, 

). After interviewing several professionals, activists and people with lived experience, I came to the conclusion that cities like Portland or Vancouver do not have a “drug crisis” per se. Instead, they have a social inequality and social exclusion crisis. The real problem is poverty, lack of housing, poor mental health, unresolved childhood trauma and all the suffering that comes with surviving street life. The sad truth is that drug use is the only way to ease this suffering for too many people abandoned by dysfunctional families, dysfunctional education, and dysfunctional healthcare systems.

Middle-class Europeans and Americans like me feel very uncomfortable even witnessing this suffering as passersby. We are disturbed by seeing homeless people scoring a fix in dark alleys and underground locations. Not only because we are disgusted (surely, we are), but also because we feel a certain moral insecurity in our own privileged position. We want to believe that we live in a just world where everyone gets what they deserve. We like to believe that everything we have achieved is because we are talented and virtuous. We are afraid to be reminded that the world we live in is unjust and that if we happened to be born into a less advantaged family, we could end up exactly where they are.

Although concerns about growing homelessness and street drug use can be valid, using the criminal justice system and law enforcement as tools for urban remodelling will lead to a dead end. Decriminalisation is necessary to connect marginalised people who use drugs into society; however, it will not change anything overnight, and it is not sufficient. It needs to be supplemented with a long-term strategy to improve social inclusion, invest in housing and create protected workplaces, educational institutions, treatment centres, and harm reduction programs that are sensitive to the specific needs of local communities. 

 to regulate substance use and provide controlled access to people who struggle with dependence should be introduced.

It is reasonable to expect that innovative social policies, such as decriminalisation or regulation experiments, should be carefully monitored and evaluated. However, these evaluations should be made by professionals, researchers, and people with lived experience. Policymakers should listen to those who present evidence rather than to those who can generate negative press coverage through political and business interests. The evidence is there, 

published by researchers in peer-reviewed papers

, demonstrating that the reform in Oregon has produced positive results. Thanks to Measure 110, more people can access services.

Drug policy reformers and harm reduction advocates should learn from the dangerous trends of re-criminalisation too. Educating the public about what decriminalisation is is just as important as explaining what it is not: it is not a universal panacea (IDPC has 

). We should be careful about using international examples, such as Portugal, to raise false expectations. The public should understand that the main problem is not drug use. The main problem is that large segments of society are traumatised and excluded and feel isolated, alienated, and disconnected. This is what really fuels the so-called “drug crisis”, whether it manifests in overdoses or crime.

I have learnt from Dr. Gabor Mate, a friend and mentor of mine, that trauma is disconnection, and healing from trauma is reconnection to ourselves and others. To live an authentic life and find what the renowned psychologist Viktor Frankl identified as the most important element of happiness: meaning, we need the same healing on a societal level. We, as a society, need to reconnect with marginalised people and not re-criminalise them.

Peter Sarosi

P.s.

There is a joke about a policeman who is patrolling the streets late one night when he sees a drunk man down on all fours, crawling on his hands and knees on the road, searching for something on the ground under the streetlight.

“Hello, what have you lost?” the policeman asks.
“I am searching for my key,” the drunk man answers.
“Ok, I will help you look,” says the policeman and joins the drunkard in his search.

After a while, the policeman asks, “Are you sure, sir, that you dropped your key here?”
“No, actually over there, in front of my house.”
“So why are you searching for it in the street?”
“Because there is more light here.”

When governments design drug policies, they often do the same as this drunk man. They look for an explanation and a solution where there is none. Because they feel more comfortable solving complex social problems with simplistic tools rather than exploring difficult territories where the real solutions lie: to build solidarity, social equality and justice.

Don’t blame decriminalisation for the failure of a hundred years of prohibition

Permission for the use of the two Category 5 drugs was announced in a directive of the ministry that was published in the Royal Gazette on Tuesday.

The directive, which was signed by Public Health Minister Cholnan Srikaew, took effect on Wednesday.

The directive referred to opium and psilocybin mushrooms, better known as magic mushrooms for their hallucinogenic effects when eaten, as narcotics on the Category 5 list, which are not extracts of marijuana and hemp.

Thailand allows use of opium, magic mushrooms for medical purposes, research

We are greatly concerned by the news that the Government of Singapore has issued at least four execution notices since 12 April 2024, all cases in relation to drug offending. Transformative Justice Collective, a member of the Anti-Death Penalty Asia Network, reports that in two of these four cases, the execution was stayed at the last minute. This leaves two people on death row at imminent risk of execution. The mental anguish persons on death row and their families experience in circumstances where execution warrants are issued is unimaginable.

Of particular concern is that it appears that all of these individuals have had execution warrants issued whilst being party to a pending Court application. The lack of transparency in relation to the use of the death penalty in Singapore, also means that it is unclear what procedural steps took place which led to the execution warrants being issued, and continuing to be issued, whilst a Court proceeding is on foot.

Safeguard no.8 of the UN Safeguards guaranteeing protection of the rights of those facing the death penalty, adopted by two UN bodies in 1984 without a vote, states that "[c]apital punishment shall not be carried out pending any appeal or other recourse procedure or other proceeding relating to pardon or commutation of the sentence". In the narrow circumstances in which the death penalty may be imposed under international law - which do not include drug trafficking - the criminal justice system should allow a robust testing of the individuals’ right of review up and until, the gallows.

If the reports that Attorney-General’s Chambers (AGC) have sought to expedite the hearings of the Court application on foot are correct, the decision-making process behind AGC’s position ought to be transparent, given the seriousness of the nature of these proceedings. Expediting cases through the judicial process undermines the ability to properly prepare and run a case, especially when the penalty is death. We therefore appeal to the AGC to ensure that the fair trial rights of all persons on death row are upheld.

In December 2022, 125 countries voted for a resolution on a moratorium on the use of the death penalty at the United Nations General Assembly. We reiterate that the notion of national sovereignty cannot be used to undermine or negate the State’s obligation to protect the right to life. Death sentences that violate international fair trial standards are a violation of the right to life. Despite international law clearly restricting the death penalty to the ‘most serious crimes’ understood as intentional killing, Singapore remains one of only a handful of countries that continue to execute individuals for drug offences. We join the call of the Transformative Justice Collective that the State of Singapore must halt these executions and declare a moratorium on its use of capital punishment as first steps.

Singapore: execution warrants issued despite pending legal proceedings

The use of the new psychoactive substances (NPS) became widespread in Hungary in the 2010s. Synthetic cannabinoids are the second most tried substance among young people after real cannabis. Still, regular use of these drugs is more prevalent among people of lower social status, who live in rural areas. According to 

, a neuroscientist, the problem with synthetic cannabinoids is not the molecule itself, but rather the dose and frequency of use. These drugs are often mixed so strongly that the typical effect will be overdose; we see this on the streets and in public squares.

The biggest problem with the use of "herbal" and "crystal" is seen in segregated areas in Hungary, where mostly Roma people live. Even in wealthier settlements, such as Halmajugra, the use of "crystal", or synthetic cathinone, is already a serious problem, mainly due to the increase in petty theft. According to 

, the mayor of the settlement, even though not all new psychoactive substance users are Roma, this is more noticeable among poorer people, so the stigma surrounding drug use impacts Roma people. Meanwhile, affected families feel that they cannot count on any external help and that they do not know whom to turn to.

Over the past 14 years, services helping drug users have been cut down and underfunded by the Hungarian state, drug prevention specialists have been banned from schools, and low-threshold services have ceased or are vegetating. According to sociologist 

, coverage of the care system has become so poor that it is simply impossible to know what is happening to these people. There is hardly any contact with people in rural areas who have drug problems. If they do get into treatment, 

 says, services are currently not differentiated enough to meet the new types of needs.

Two employees of the Laurus association, 

, are doing heroic work in the segregated district of the Miskolc Iron Factory. They maintain a community space and provide therapeutic help to people living with drug problems. Additionally, they support local children, which they consider one of their most important tasks. They want young people to know that they have someone to turn to when they have problems, and by doing so, they aim to reduce the re-emergence of segregation. 

, their peer worker, was able to start a new life with the help of Laurus and stop injecting “crystal”. According to Helga's family, the greatest opportunity to break out of the segregation of the ironworks was the emergence of job opportunities provided by factories and the European Union.

, a social worker and assistant professor at ELTE, without reforming the educational, health care and child protection systems and investing in infrastructural developments, such as transport solutions and repairing roads, they will not be able to deal with problematic new psychoactive drug use in segregated areas.

As long as there is a demand for drugs, there will be dealers. In the hope of making quick money, 

 from Komló became a dealer from being a Cash-in-Transit security guard. He quickly climbed to the top, earning the price of his car in one evening. However, in order to cope with the constant strain of this work, he got hooked on his own drugs. He got so deep that he even became homeless for a while. Yet, he believes that society is holding up a twisted mirror to us and that the media does not present a realistic picture of drug users. According to him, users of synthetic cathinones do not typically end up in the state synthetic cannabinoid users are often portrayed in the media – lying in an underpass, hunched over, and fainting. The drug can give and take, but he thinks that as an adult, one can decide what they want, and he holds himself responsible for his own fate. When he had enough, he stopped using intravenous drugs on his own and went back to work; still, he lost his family. According to Benjámin, this area should not necessarily be seen as a problem, as some synthetic drugs could be regulated. If you can do it with cannabis, you can do it with these as well.

The primary response of the Hungarian state is criminalisation. The use of drugs is a criminal offence, and the use of NPS is a misdemeanour. However, acknowledging the senseless and excessive nature of imprisonment, the state introduced the institution of ‘diversion treatment’, which one can choose instead of punishment. But this can only be chosen once in two years. However, in the case of designer drugs, since possession of these is "only" a misdemeanour, this is not allowed even once.

ABANDONED: Designer Drugs on the Margins of Hungarian Society

: To inform the Special Rapporteur's thematic report to the General Assembly in October 2024.

Within the framework of Human Rights Council resolution 51/21, the 

Special Rapporteur on the highest attainable standard of physical and mental health

 has identified health equity as a strategic priority, ranging from the underlying determinants of health to the need to eliminate structural and systemic barriers in accessing health care services, goods, and facilities, particularly among persons living under vulnerable or marginalised circumstances. In compliance with her mandate, in line with these priorities and to build on the report she will be presenting to the 56th session of the Human Rights Council in June 2024 on “Drug policies and responses: a right to health framework on harm reduction.”, the Special Rapporteur on the right to health has decided to devote her next thematic report to the 79th session of the General Assembly, in October 2024 to the theme of “Harm reduction for sustainable peace and development”.

The Special Rapporteur stresses that all individuals are entitled to the enjoyment of the right to health, which includes the underlying determinants of health and timely and appropriate health care. In the present report and building on the report she will be presenting in June 2024 during the 56th session of the Human Rights Council[

], the Special Rapporteur intends to explore the ways in which harm reduction intersects with the right to health and related human rights. Relying on the frameworks of the social, commercial[

] determinants of health, the Special Rapporteur will examine harm reduction legislations, policies and programmes linked with sustainable peace and development, as well as universal health coverage, harm reduction in situations of vulnerability.

In the forthcoming report, the Special Rapporteur intends to focus on harm reduction as key public health interventions for populations that are often stigmatised and discriminated against. The Special Rapporteur will use an intersectional, anti-racist and anti-colonial approach in her analysis related to drug use, harm reduction and the right to health and will thus examine the underlying power structures that perpetuate systems of disadvantage that determines who have acceptable, accessible, affordable, and quality services, goods and facilities.

The achievement of Universal Health Coverage is challenged by the lack of health equity and the Special Rapporteur will also examine gaps in adopting a rights-based approach to public health and harm reduction, including in contexts in which it fails to meet the needs of those who bear the brunt of punitive drug laws and policies and inadequate comprehensive support over decades.

The Special Rapporteur will explore how harm reduction is a part of reparative approaches through evidence based, stigma-free, decriminalised legislations, policies and programmes linked with universal health coverage, sustainable peace and development.

Most commonly, harm reduction refers to policies, programmes and practices that aim to minimise the negative health, social and legal impacts associated with drug use, drug policies and drug laws[

]. For the purposes of this report, the Special Rapporteur defines harm reduction in a broader sense, including the policies, programmes, and practices that aim to minimise the negative health, social, and legal impacts associated with various behaviours and related policies and laws, as exemplified above.

Key questions and types of input/comments sought

Please provide the specific challenges, or positive developments and examples of harm reduction interventions in communities, countries, or regions. If possible, please provide examples of how harm reduction support programmes in your community, country, or region were impacted by war, conflict, crisis or humanitarian settings and steps, if any, that were taken to mitigate the impact.

Please share the impact of criminalisation, discrimination, stereotypes and stigma in your community, country, or region on the accessibility, availability, affordability, and quality of essential medicines (e.g., pain medication or abortion pills), palliative care, comprehensive drug prevention and education, and drug treatment?

Please provide examples of initiatives undertaken to provide access to controlled medicines to specific groups of the population requiring them.

Are there resource or budgetary requirements or constraints for adopting or implementing sound harm reduction policies, programmes, and practices in your community, country, or region? How do the resources allocated to harm reduction compare to those allocated to law enforcement or the criminalisation of drug use or other behaviours? How do universal health coverage plans/implementation in your region take harm reduction resourcing into account?

What role do private actors (e.g., the pharmaceutical, tobacco, alcohol, food industries) play in real or apparent harm reduction policies, programmes, and practices that are available in your community, country, or region? What are the positive or negative impacts to public health, sustainable peace and development?

In your opinion, what constitutes comprehensive clinical guidelines/procedures? Please provide good practices in this regard implemented in your community, country, or region. Does universal health coverage implementation reflect these good practices?

Please provide examples of good initiatives or practice undertaken to provide comprehensive harm reduction interventions for populations that are often criminalized, stigmatized and discriminated against in the context of drug use and drug laws and policy.

Please provide details about the type of continuous professional training related to international human rights norms and standards provided or offered to staff working in the judiciary, law enforcement, community safety, medical practitioners, and educators.

Please share the redress mechanisms in place, if any, to ensure that the right to health of people who use drugs are protected.

In view of anti-colonial and anti-racist approaches to harm reduction related to drugs, please provide some examples of reparative approaches that protect and promoted the dignity of people.

Please note that all responses will be published on the official webpage of the Special Rapporteur by default.

Inputs may be sent via e-mail by 27 May 2024.


Contribution to GA report - SR right to health

Harm reduction for sustainable peace and development - Call for inputs

As early as November 2022, Department of Justice (DOJ) Secretary Jesus Crispin Remulla has voiced his support in crafting a new policy direction in the government's fight against illegal drugs.

This was disclosed by DOJ Undersecretary Jesse Jerogenes Andres in his keynote speech yesterday at the launch of the Philippine Drug Policy and Law Reform Summit held at the Malcolm Hall of the University of the Philippines in Diliman, Quezon City. He said the government is poised to enact meaningful laws that is aligned with the shared vision for a better future.

Andres said this guarantee is contained in the fundamental law of the land particularly the constitutional bill of rights, thus all aspects of governance should express the primacy of human rights.

At present, Andres said that the convening of the Philippine drug policy summit it is also a pivotal moment of history and should stand to catalyze a new era of collaboration, innovation, and progress to build a safer, healthier and more humane society.

The summit will deal more with dialogue with stakeholders that transcends boundaries and to foster a supportive and conducive environment and the key is to listen and understand.

Also, the commitment of every person in the summit will be harnessed towards the power of collective wisdom, collective action, and responsibility in order to forge solutions that have far reaching impact and yet sustainable.

Philippines' Department of Justice mulls support in crafting new drug policy

The Senate is expected to vote in the coming days on an amendment to article 5 of Brazil’s Constitution, which guarantees the right to privacy, that would restrict that right by criminalizing the possession of illegal drugs regardless of quantity. If approved, the proposed amendment would be put to a second vote at the full Senate and then go to the Chamber of Deputies.

“Decades of drug policy failure in Brazil should make clear that criminal law is simply ineffective to address the harmful use of drugs and leads to serious human rights abuses,” said Andrea Carvalho, Brazil researcher at Human Rights Watch. “Instead of cementing a failed policy in the constitution, lawmakers should follow the example of many other countries by decriminalizing the possession of drugs for personal use and developing effective health strategies to prevent and respond to problematic substance use.”

Current law already criminalizes drug possession for personal use, but introducing this language in the constitution would make it much harder to pursue much-needed drug policy reforms in Brazil, Human Rights Watch said.

The president of the Senate, Rodrigo Pacheco, has made clear that the constitutional amendment is a pre-emptive attempt by lawmakers to counter an upcoming Supreme Court decision that could improve drug policy, Human Rights Watch said. Pacheco introduced the proposal on September 14, 2023, a few weeks after the Supreme Court resumed its review of a case that will decide whether current Brazilian law violates the Constitution. Upon introducing the bill, Pacheco stressed that it is Congress that “defines the laws in the country” and other branches of government should recognize that authority.

Brazil: Reject bill that entrenches failed drug policy

Unintentional drug overdose deaths are a critical public health concern nationally and locally; New York City (NYC) reported 3,026 overdose fatalities in 2022, the highest number of overdose deaths citywide since reporting began in 2000. The burden of overdose deaths is highly unequal: older New Yorkers, Black and Latino/a New Yorkers, people experiencing homelessness, and residents of high-poverty neighborhoods continue to experience the highest rates of fatal overdose citywide. The rise in overdose deaths is driven by the proliferation of fentanyl, which was present in 81% of overdose deaths in NYC in 2022. Overdose prevention centers (OPCs), also known as supervised consumption spaces, have demonstrated international success in reducing overdose deaths and associated harms. OPCs provide hygienic spaces where people can use previously acquired substances under the supervision of trained staff. These OPCs, which opened in NYC on November 30, 2021, are recognized as the first OPCs with supervised use of illicit substances to be formally supported by a governmental entity in the United States. The OPCs are operated by the nonprofit organization OnPoint NYC; the City of New York provides monetary support for many services at the OPCs except direct supervised consumption, as well technical assistance and programmatic oversight by the NYC Department of Health & Mental Hygiene. This report summarizes the first year of operations of these two centers in NYC. From November 30, 2021, to November 30, 2022, 2,841 individuals visited the two OPCs 48,533 times and staff intervened during 636 visits (1.3%) to prevent overdose-related injury and death. During this period, emergency medical services (EMS) were called only 23 times, and no overdose deaths occurred in the OPCs. Results suggest that the OPCs diverted up to 39,000 instances of public drug use and played a critical role in connecting participants to care, with 75% of participants accessing other harm-reduction, social, and medical services through OnPoint NYC. Despite these early successes, these and other OPCs face challenges sustaining operations in uncertain legal and law enforcement, legislative, and funding environments. Additional research exploring the needs of participants, patterns of OPC service utilization, and the long-term impacts of OPC use on health outcomes is needed to expand the body of evidence supporting OPCs in the United States.

 to read the full article (restricted access).

New York City’s overdose prevention centers: data from the first year of supervised consumption services

KARACHI -- Pakistan is establishing a legal framework for cannabis trade after the government approved the herb for industrial uses nearly four years ago, hoping to capitalize on the booming market to increase its foreign exchange reserves.

A presidential order passed in February delineated rules for the formation of Pakistan's first Cannabis Control and Regulatory Authority. The government approved cannabis for industrial use in September 2020 but had not established a regulatory framework due to internal conflict.

"We are very serious about this initiative, and things are moving at a very fast pace," a senior official of the Special Investment Facilitation Council, which is spearheading government efforts to draw investments and overhaul the economy, told Nikkei Asia.

The new coalition government -- formed of the Pakistan Muslim League-Nawaz (PMLN) and Pakistan Peoples Party (PPP) -- is setting up the regulatory body to formulate policies, such as issuing licenses to growers and sellers, and earmarking regions for cultivation, the official added.

Pakistan hopes to take advantage of its conducive growing conditions to enter the global cannabis market, that according to Indian research company MarketsandMarkets, will grow to $82.3 billion by 2027 from $27.2 billion in 2022. The country is seeking ways to increase exports and raise taxes to break its dependency on foreign loans and bailouts from the International Monetary Fund.

Pakistan sets cannabis rules, eyes sales to help balance books

Drug use is now re-criminalised in Oregon – what are the lessons learnt for drug reformers? We interviewed Theshia Naido, Legal Director at the Drug Policy Alliance.In 2020, voters in the state of Oregon approved Measure 110, effectively decriminalising the use of illicit drugs and expanding social and health services by redirecting cannabis tax revenue and law enforcement savings. The Measure did not only significantly reduce criminal spendings but it resulted in a dramatic increase in the number of clients accessing services. However, after a steep increase in overdose deaths and homelessness-related suffering on the streets, although not caused by decriminalisation itself, a campaign was launched by opponents of drug policy reform, which scapegoated Measure 110 for all the problems. Drug use was re-criminalised in 2024 and Oregon became an exemplary tale of the “failure” of decriminalisation in the Conservative press. In this interview, we address common misunderstandings and misinformation about decriminalisation.

Re-criminalisation of drug use in Oregon, United States

On March 14-22, 2024, the UN Commission on Narcotic Drugs (CND) held its 67th annual session in Vienna, Austria. The session saw a landmark vote that may have important repercussions for drug policy, in Latin America and elsewhere.

The Commission approved a U.S.-led resolution encouraging countries to implement “harm reduction” measures to respond to drug overdoses and to protect public health.

The vote marks a major breakthrough in civil society’s decades-long advocacy to center harm reduction, especially since the U.S. government has a history of blocking all such resolutions, and since the Commission has a longstanding tradition of enactment by a “Vienna Consensus” without votes.

Download the episode .mp3 file of WOLA's Latin America Today podcast here

A groundbreaking win at the United Nations Commission on Narcotic Drugs

While there have been reductions in the rates of most major causes of death among people with HIV in North America and Europe since 1996, people who inject drugs – particularly women – remain vulnerable to early death.

Before 1996 – when combination antiretroviral therapy (ART) became the mainstay of HIV treatment – death from AIDS was a near inevitability, even in high-income countries. Due to ART’s high effectiveness at suppressing HIV, AIDS-related deaths have declined steeply, particularly in Europe and North America. However, between 1996 and 2012, ART was usually only started when a person’s CD4 count fell below a certain level or based on symptoms. This changed globally based on conclusive findings from the INSIGHT START and TEMPRANO studies – these indicated that immediate ART initiation leads to the best outcomes, regardless of CD4 count and disease stage. Thus, test and treat approaches that aim to minimise the time between diagnosis and starting treatment were implemented globally between 2012 and 2015. People living with HIV on effective treatment are now more likely to die at an older age from age-related illnesses, such as heart disease or cancer than AIDS. Additionally, death from substance use and hepatitis C remains higher among people living with HIV.

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