In November 2012, voters in two US states – Washington and Colorado – approved ballot initiatives to establish legally regulated markets for the production, sale, use and taxation of cannabis (commonly referred to in the US as marijuana). This is the first time anywhere in the world that the recreational use of the drug will be legally regulated – the wellknown coffee shop system in the Netherlands is merely tolerated rather than enshrined in law.

Needless to say, with implications both within and beyond US borders, the drug policy community is watching Colorado and Washington closely. The votes not only put these US states in contravention of US federal law, but also generate considerable tension between the federal government and the 1961 United Nations Single Convention on Narcotic Drugs, the bedrock of the international drug control regime that the US has so worked so hard to construct and sustain.

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Legally regulated cannabis markets in the US: Implications and possibilities

The response of national governments to illicit drugs is a challenging area of public policy for many reasons. In most countries it is an extremely politicised domain in which repressive policy measures may be adopted despite evidence suggesting that they are ineffective, often rather because political leaders want to show that they are “tough on drugs”. In addition, sometimes the evidence on which even the best-intended policies could be built is patchy or unreliable.

This report analyses the situation of West Africa as regards drug trafficking and consumption of illicit drugs.

Telling the story of drugs in West Africa: The newest front in a losing war?

Situated along the ancient Silk Road linking Europe to Asia, Kyrgyzstan has become an increasingly important transportation corridor for Afghani opium and itinerant labor. This has fueled epidemics of bloodborne and sexually-transmitted infections (STIs) among people who inject drugs (PWID), sex workers, and migrants.

The prevalence of HIV reaches 50 times and 5 times the background rate among PWID and sex workers, respectively; three-quarters of Kyrgyz HIV cases can be directly or indirectly attributed to injection drug use (World Health Organization, 2009).

Kyrgyzstan's experience suggest that police trainings have the potential to improve the integration of policing and public health efforts targeting at-risk groups.

Police education as a component of national HIV response: Lessons from Kyrgyzstan

Scaling up HIV prevention interventions in Central Asia will demand greater attention to the structural, health-care-related and social factors that facilitate HIV risk and impede service utilization among PWID. Multi-level combination prevention interventions should be developed with a focus on the sexual partners and risk networks of PWID, aiming at early detection of HIV, timely enrollment in HIV care, and retention in HIV care.

Scaling up HIV prevention efforts targeting people who inject drugs in Central Asia

Over the last decade, Central Asia has become a focal point of HIV and hepatitis C virus (HCV) transmission among people who inject drugs (PWID). PWID account for the majority of HIV infections in most countries in the region, while a large proportion have been exposed to HCV. Shared modes of transmission of these infections point to an increasing burden of HIV/HCV co-infection in this population. HIV/HCV co-infection is more likely to result in progressive liver disease, increased mortality and hepatic complications from antiretroviral therapy (ART).

While the HIV treatment response has improved, less than a quarter of people living with HIV (PLHIV) in the region are receiving ART, with treatment uptake among PWID particularly low. HCV treatment is available in some areas, though at a very high cost to patients thereby preventing access to those at most need.

HIV and HCV among people who inject drugs in Central Asia

Rates of tuberculosis in Central Asia are extremely high, and even more alarming are the very high rates of multidrug-resistant tuberculosis (MDR-TB) in Kazakhstan, Uzbekistan, Tajikistan and Kyrgyzstan. In addition, rates of HIV infection related to injection drug use seems to be rising as well, thus creating conditions for a potentially devastating co-epidemic of TB/HIV and MDR-TB/HIV which would have terrible consequences for public health in these countries.

In many countries of Central Asia, diagnosis of tuberculosis still rests on clinical grounds or simple technologies such as chest radiograph and sputum smear examination. Modern molecular techniques such as GenExpert are being introduced in Kazakhstan and Uzbekistan, and perhaps soon in Kyrgyzstan. Treatment of TB is still often centered around prolonged inpatient stay at TB hospitals. Only a minority of patients with HIV infection are receiving ART, and TB and HIV services are not well integrated. Needle exchange programs are becoming increasingly available, but opioid substitution therapy is rarely used in Central Asia. TB, drug treatment and HIV services are generally not well-integrated.

Tuberculosis, drug use and HIV infection in Central Asia: An urgent need for attention

Ever since its foundation in 2007, the Middle East and North Africa Harm Reduction Association (MENAHRA) has worked to support harm reduction based on scientific data. Unfortunately, in our region, there are a limited number of empirical studies available besides the bio-behavioral studies conducted by individual countries. There is an apparent weakness in the epidemic surveillance systems for the proportions of HIV prevalence. This gap reflects a lack of priority in the region in providing harm reduction services. It also confirms that sharing needles is the second cause for HIV/AIDS transmission in the MENA region.

This study arises from within MENAHRA's course of work to search for the reality of the situation with an empirical approach in order to increase the level of response to HIV/AIDS in the region.

This report should allow decision-makers and civil society organizations to expand their knowledge in regards to the needs and weaknesses of available services by guiding programs in becoming more focused on harm reduction in the region. Therefore, this report shall assist stakeholders in providing a wider scope of HIV/AIDS prevention services among people who inject drugs.

Assessment of situation and response of drug use and its harms in the Middle East and North Africa

The year before US and International Security Assistance Force (ISAF) troops are scheduled to withdraw from Afghanistan and as security arrangements going forward remain unclear, opium poppy cultivation has reached an all-time high, rising an estimated 36% between 2012 and 2013 to over 200,000 hectares. Opium production has doubled to an estimated 5,500 tons.

The US led invasion of Afghanistan in 2001 was justified through reference to regime change and counter terrorism. Although former British Prime Minister Tony Blair cited Afghanistan’s role in the drug trade as a factor influencing his decision to support the invasion, there was no explicit strategy for narcotic drugs, despite opium’s complex, historical inter-relationship with conflict and development in the country. Further relegating consideration of the drug dimension down the list of priorities and objectives was the collapse of opium poppy cultivation in 2001 following an effective campaign decreed by Taliban leader Mullah Mohammed Omar and which was conducted with some collaboration with the UN drug control apparatus. While producing a range of negative consequences in terms of economic wellbeing of rural communities, this reduced the total area under opium poppy cultivation to below 8,000 hectares.

Afghanistan’s bumper opium harvest

Uptake of harm-reduction services among women is low in the Middle East and North Africa (MENA) region. A qualitative operational research was conducted to provide recommendations on how to improve the uptake of harm reduction services among women injecting drug users (WIDUs). By understanding the factors that influence service uptake, program managers can develop meaningful strategies to increase uptake of their services.

To explore the context of drug use among WIDUs

To identify barriers and facilitators to accessing harm-reduction services

To provide recommendations on how to improve access to harm-reduction services.

Women injecting drug users in the Middle East & North Africa Region 

In 2010, the 63rd World Health Assembly (WHA) adopted the first resolution on viral hepatitis (WHA63.18). A new resolution will be presented at the 67th WHA.

Globally, an estimated 185 million people have been infected with hepatitis C virus (HCV). Since 2010, more than a million people have died from HCV, although it is treatable and curable. Nine to twelve million people have been infected since 2010, although HCV is preventable. Most new infections occur among people who inject drugs (PWID), yet access to HCV prevention tools (such as sterile injection equipment) is woefully inadequate, reaching a tiny percentage of those who need it. This shocking public health failure allows the epidemic to continue spreading.

Only a tiny fraction of people who have been infected with HCV are aware of their status. Most live in low and middle-income countries (LMICs) and have no access to diagnostics, care, or treatment. Pegylated interferon (peginterferon, or PEG-IFN), the backbone of the current standard of care for HCV, is priced cruelly out of reach. Even in places where HCV treatment is available, injecting drug use is often used as a criteria for denying access: only 2-4 percent of people who inject drugs are currently receiving treatment.

We, people living with HCV, HIV/AIDS, people who use drugs and our advocates, urge United Nations Member
States to act strongly in order to tackle the hepatitis C epidemic; it is feasible!

Defuse hepatitis C, the viral time bomb!

Ahead of World AIDS Day on 1 December, the 

 has released today a new toolkit offering countries the latest guidance on monitoring infectious diseases, such as HIV/AIDS and viral hepatitis (B,C), among people who inject drugs (PWID). The toolkit is designed to help health professionals improve their monitoring practice in order to reduce the burden of disease in this vulnerable group and improve the coverage and quality of services delivered.

Prepared closely with experts, country representatives and international and EU agencies, the toolkit updates earlier guidance, and presents new monitoring methods and indicators in a more flexible and user-friendly format.

EMCDDA toolkit - Drug-related infectious diseases 

In most European Union (EU)/European Economic Area (EEA) countries, between 2010 and 2012, reports of new human immunodeficiency virus (HIV) diagnoses among people who inject drugs have been stable or declining. HIV outbreaks in Greece and Romania, first reported in 2011, continue and economic conditions hinder provision of effective response coverage. When measured against some established thresholds, prevention coverage remains inadequate in at least one-third of EU/EEA countries. Urgent consideration to scale up prevention efforts is merited.

In response to sharp increases in human immunodeficiency virus (HIV) notifications reported among people who inject drugs (PWID) in Greece and Romania, a risk assessment of HIV transmission among PWID was carried out in the European Union/European Economic Area (EU/EEA), Croatia and Turkey, in 2011. The report, covering 31 countries, confirmed outbreaks among PWID in Greece and Romania and noted a potential for outbreaks elsewhere [1,2]. This update, based on a survey conducted in mid-2013, summarises developments in HIV transmission and injecting risks among PWID since 2010 and identifies areas where scale-up of evidence-based preventive measures is needed to avoid further outbreaks.

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