Spread across Brazil and attaining an unparalleled political force, therapeutic communities are as inescapable in the debate on drug policy as they are complex to define. Although they are not a Brazilian creation, they have been operating in that country for decades, and their dissemination intensified in the 1990s. In 2011, they were officially incorporated into Brazil's Psychosocial Care Network (Rede de Atenção Psicossocial, or RAPS). Since then, therapeutic communities have been at the center of public debates about their regulation; about how they should—or even if they should—be a part of the healthcare system; about the level of supervision to which they should be submitted; about their sources of funding, particularly whether or not they should have access to public funding; and, most importantly, about the quality of the services they offer and the many reports of rights violation that have been made public.

However, a well-informed public debate can only flourish if the available information is based on sound evidence. The SSRC’s Drugs, Security and Democracy Program is concerned with the policy relevance of the research projects it supports, and the debate around therapeutic communities in Brazil points to a clear need for impartial research that addresses different cross-cutting aspects of this topic in its various dimensions: legal, regulatory, health, and observance of human rights, among others.

It is in this context that we publish this working paper series on therapeutic communities in Brazil. The eight articles that compose this series offer a multidisciplinary view of the topic, expanding and deepening the existing literature and offering powerful contributions to a substantive analysis of therapeutic communities as instruments of public policy. Although they can be read separately, it is as a whole that the strength of the eight articles that make up this series becomes more evident. Even though they offer different perspectives, they are complementary works in—and already essential for—delineating and understanding the phenomenon of therapeutic communities in Brazil.

Therapeutic communities in Brazil

Funding for HIV programs tailored to the needs of gay and bisexual men and other men who have sex with men, sex workers, people who inject drugs and transgender people remains shockingly low worldwide: only 2% of global funding for HIV programs targets key populations. Yet according to UNAIDS, key populations and their partners accounted for 62% of new adult HIV infections in 2019.

The Global Fund to Fight AIDS, TB and Malaria (The Global Fund), has made reaching key populations a top strategic priority, and has set up a variety of policies, procedures, and technical support opportunities toward that end. Nevertheless, the complexity of these mechanisms can cause challenges for key populations working to access those funds.

At a country level, key populations advocates can influence their country’s overall priorities by participating in the Country Coordinating Mechanism (CCM). CCMs are national committees that write and submit funding applications to the Global Fund, and that oversee the implementation of successful grants on behalf of their countries. They are comprised of representatives from across government, implementing partners, people living with the three diseases, technical experts, and grant writers, among others.

Officially, CCMs are spaces where advocates can push for the inclusion of key populations programs in funding applications to the Global Fund. (Notably, the Global Fund requires representation of all key populations at the CCM - see more about Global Fund commitments to Key Populations in Part 3, below). The reality, however, can be challenging; just being ‘in the room’ is not enough.

Roadmap for key populations advocates navigating the Global Fund

Over 11 million people are imprisoned worldwide today, the highest number ever recorded. Globally, the dominant response to drugs remains prohibition-based drug policies backed by criminal sanctions that have contributed to the increase in the prison population.

Despite some moves towards the decriminalisation and regulation of drugs, drug offences remain one of the biggest drivers of incarceration. At least one in five people in prison globally is held for drug-related offences. Approximately half a million people are serving sentences for personal drug possession. UNAIDS estimates that up to 90% of people who inject drugs will be incarcerated at some point in their life. There are also more than 400,000 people detained in forced rehabilitation and compulsory drug detention centres in Asia alone, with forms of compulsory drug treatment also existing in Latin America and the Caribbean, Eastern Europe and Central Asia and elsewhere. This punitive approach has the greatest impact on already marginalised populations, including women, racial and ethnic minorities, indigenous people and foreign nationals.

Incarceration is also an enormous waste of money and resources. Over USD 100 billion is spent globally on drug law enforcement every year, but just USD 131 million was spent on harm reduction in low- and middle-income countries in 2019. This means that we spend more than 500 times the amount on punitive responses than we do on life-saving services for people who use drugs.

Systematic reviews of evidence find that there is no clear link between imprisonment and crime rates or between compulsory treatment and drug use. In fact, there is more evidence for links between reduced welfare systems and social inequality, and increased imprisonment rates. Nevertheless, in many countries, and even more so in the context of a surge of oppressive regimes in many parts of the world, the punitive “lock them up” response to drugs remains the easiest answer to a complex issue.

The harms of incarceration: The evidence base and human rights framework for decarceration and harm reduction in prisons

In this submission to the UN Special Rapporteur on health, IDPC, Corporación Humanas Colombia, and Penal Reform International provide some examples of the impact of the COVID19 pandemic on the sexual and reproductive health of incarcerated women, with a focus on period poverty.

Approximately 740,000 women are deprived of liberty across the world. An estimated 35% of them are in prison for drug offences, though that percentage is much higher in the countries with larger female prison populations, particularly in the Americas, and in South East Asia.

The world’s prison systems have been built by, and for, men. Women's specific needs are routinely ignored and deprioritised. One of the best examples of this trend is the disregard for the right to sexual and reproductive health of women deprived of liberty. This submission focuses on a particular aspect of this problem: the lack of access to menstrual health products, such as sanitary towels, for women who are in prison – also known as period poverty.

Even before the pandemic, in many countries women deprived of liberty had to rely on their family for the supply of menstrual health products, or for money to buy such products within prisons themselves.

When the pandemic hit these prison systems, the preferred response by many authorities was to completely cut off any visits and contact between prisons and the community, thus leaving women deprived of liberty with no access to the most basic menstrual health products.

Drawing on several country examples, and particularly on the research of Corporación Humanas Colombia, this submission explains this phenomenon, and how it constitutes a serious breach of the right to sexual and reproductive health of women deprived of liberty.

Period poverty in prisons during the COVID-19 pandemic: Submission to the UN Special Rapporteur on health

Despite the COVID-19 pandemic and its associated restrictions on mobility of trade and transport, the methamphetamine market in East and Southeast Asia has continued to expand. While Shan State, Myanmar, remains the main source of illicit manufacture of methamphetamine in the region, there are growing signs that Cambodia is being increasingly targeted for large- scale illicit methamphetamine manufacture, showing organized crime diversifying their methamphetamine supply channels.

As for the past decade, the total amount of methamphetamine seized in East and Southeast Asia has continued to increase, reaching another record level in 2020 with preliminary data showing at least 169 tons of methamphetamine seized. Though there was a decline in seizures in East Asia, it was more than offset by the increase in seizures in Southeast Asia, largely due to the lower Mekong countries,1 which accounted for 71 per cent of the total amount of methamphetamine seized in East and Southeast Asia.

Several trafficking routes have emerged, and seizures of methamphetamine point to diversified sources of the substance. Lao PDR has been increasingly targeted for transit and trafficking of methamphetamine and its related chemicals, as indicated by sharp increases in seizures of the drug along the border between Lao PDR and northeastern Thailand. Sources of methamphetamine have diversified beyond Shan State, Myanmar, with reports of methamphetamine being trafficked to the region from West Asia and South Africa.

COVID-19 and its associated mobility restrictions resulted in only a short-lived disruption to the supply of and demand for methamphetamine. Available quarterly data from both East and Southeast Asia show a drop in seizures in the second quarter of 2020 during the height of the pandemic. However, seizures quickly rebounded from the third quarter onwards, demonstrating the flexibility of organized crime groups to adapt to change and take advantage of porous borders in the region. Wholesale prices of crystalline methamphetamine declined in several countries in Southeast Asia, namely Cambodia, Malaysia, and Thailand, while its purity remained stable, indicating limited impact on the availability of methamphetamine.

Synthetic Drugs in East and Southeast Asia: Latest developments and challenges 2021

Over forty years into the HIV pandemic, East and Southern Africa remains disproportionately affected by the disease. Despite that new HIV infections in the region have declined by 28% since 2010, in 2018 there were still 800,000 new cases – just under half of the global total.

South Africa accounts for over a quarter of new infections in the region, and countries that continue to have high case numbers include Mozambique, Zambia, Malawi and Zimbabwe. Three countries have made significant leaps towards covering 90% of the HIV care cascade: Botswana, Eswatini and Namibia. But other countries in the region lag behind.

As Southern Africa works towards reducing new infections, it is important that donors and governments examine whether their prevention budgets are considering specific populations that are vulnerable to HIV. In the region, young women (aged 15–24 years) make up only 10% of the population, yet account for 26% of new HIV infections. Nearly half of the 254,000 new HIV infections among adolescents globally in 2016 also occurred in the region. And in specific countries, key populations—defined as men who have sex with men, sex workers, people who inject drugs, transgender people and prisoners—also experience unequal infection rates. For example, in Malawi, where 9.2% of the adult population is living with HIV, one in two sex workers in HIV positive.3 Generalised prevention programmes are unlikely to reach or cater to the needs of younger people and key populations. Targeted and increased prevention funding is necessary to accelerate change.

Turning off the tap: The state of HIV prevention funding in Southern Africa

The new EU drugs strategy 2021-25 makes explicit that the European response to drugs should be evidence-based and delivered through a balanced and integrated approach, which ultimately must be judged on its impact on the health, safety and wellbeing of our citizens. The EMCDDA is tasked with helping to provide the evidence needed to ensure that European policies and actions on drugs are effective, well-targeted and responsive to new threats and challenges. The European Drug Report (EDR) 2021 arrives at a difficult time for meeting this objective, as the COVID-19 pandemic has impacted greatly on all areas of life, including the drug situation and our ability to monitor it. I am therefore extremely pleased that we can still provide the detailed analysis presented in this report, which includes an early assessment of the effect of the pandemic on drug markets and drug use. However, I also believe the value of our work is not simply delivered through accurately documenting past events. We also need to look forward and consider what lessons emerge from the findings of the EDR 2021 in order to ensure that we continue in the future to provide the relevant and timely information required to keep our policies and actions commensurate with the growing challenges we face in the drugs area.

In 2019, the EMCDDA conducted, with its stakeholders, a foresight and horizon-scanning exercise to increase our awareness of how the evolution of the drug situation may impact on our work. Among the overarching conclusions of this work was that many of the factors that would shape the drug problems of the future were external ones. Globalisation, developments in information technology, demographic shifts, alongside issues like climate change and human migration, are likely to have important implications for the future drug problems we face. We already see this, as both the drug market and patterns of drug use are becoming ever more dynamic, complex and globally connected. This has made us reflect on the need for more timely reporting, and to consider if both the data sources we use and the targets we select for our analysis are sufficient to meet both current and future policy development needs.

What we did not expect was that the events of 2020 would demonstrate so profoundly the importance of this reflection. Within a few weeks, we needed to reorientate our work to support our stakeholders by providing enhanced resources for sharing information and best practices. The speed of developments required us to recognise that this could only be achieved through a more interactive model for knowledge co-production. I am proud of the work of the EMCDDA during this period, but I recognise that this was only possible because of the input we received from stakeholders across Europe. Particularly important was the possibility provided by our Reitox network of national focal points to engage in an ongoing conversation on national responses to the pandemic. This highlighted the value of sharing experiences and preliminary information when there is a need for rapid action. Beyond this, we also launched a series of trendspotter studies to collate qualitative and emerging quantitative data to provide a near real-time complementary data source to accompany our routine monitoring information. The latest insights from our third COVID-19 trendspotter, published recently, are summarised here. These results are preliminary, but they help us identify some of the possible longer-term effects of the pandemic on drug markets, drug use and our responses.

European Drug Report 2021

This report is produced on behalf of the Civil Society Forum on Drugs (CSFD), an expert group of the European Commission, created in 2007 on the basis of the Commission Green Paper on the role of civil society in drugs policy in the EU. The CSFD membership comprises 45 civil society organisations (CSOs) from across Europe and representing a variety of fields of drug policy and stances within those fields.

One of the thematic working groups of the CSFD aims to assess and promote civil society involvement in the field of drug policy. In 2020, the working group conducted a literature review to assess existing guidelines and recommendations on how civil society can be involved in policy making in a meaningful way. Based on the findings of the review, this report presents quality standards of civil society involvement to guide both decision-makers and civil society on how to create mechanisms that facilitate the building of dialogue and partnership between them.

According to the European Monitoring Centre on Drugs and Drug Addiction (EMCDDA), quality standards are generally accepted principles and a set of rules for the best/most appropriate implementation of interventions. They are used as benchmarks, based on professional consensus, to judge whether an activity is of high quality. An example is the European Drug Prevention Quality Standards (EDPQS), which aims to guide professionals on how to design, implement, monitor and evaluate interventions in drug prevention.

Quality standards of civil society involvement in drug policies

Opioid substitution therapy (OST) is a recognized approach to treating opioid dependent people and managing the problems associated with this condition. Evidence suggests that it significantly improves the quality of life of the program beneficiaries and their loved ones. It reduces the spread of blood-borne infections, the use of illegal opioids, conflicts with the law, health-damaging and risky behaviors related to HIV transmission, overdoses and etc. (NIDA, 2018). The OST programs are supported by the World Health Organization, the United Nations Joint Program on HIV/AIDS, and the United Nations Office on Drugs and Crime (WHO, UNODC and UNAIDS, 2012).

Today, the OST programs are widely implemented in different regions and countries of the world. Based on this experience, both international and national guidelines and protocols have been developed to help meet quality standards. A number of such documents focus on clinical issues (dosing, admission criteria, treatment of groups with special needs, etc.), e.g., the guide of the World Health Organization (WHO, 2009). In addition, documents have been developed and continue to be developed that focus on more practical issues - such as how to implement and develop a program, based on the local context, i.e. the local socio-economic and cultural specifics of a country or a region (WHO, 2014).

Researching the OST programs are critical to developing manual documents and practical recommendations described above for a particular region or a country. This includes, on the one hand, the study of the program effectiveness and the effectiveness determinants; On the other hand, the study of the service satisfaction and the satisfaction determinants by the beneficiaries of the OST programs.

Survey of client satisfaction with opioid substitution program in western Georgia

The 1st ‘Brandenburg Forum (BBF) in Geneva’ took place on 11th February 2021, within the framework of the Global Partnership on Drug Policies and Development (GPDPD). The event has originally been conceived as an in-person meeting in 2020 but, in response to the global COVID-19 pandemic and related restrictions, it was delayed and then adapted to work as an interactive, three-hour online meeting instead. The Forum was cohosted by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH on behalf of the German Federal Ministry for Economic Cooperation and Development (BMZ), the German Federal Drug Commissioner, the Government of the Netherlands, the Norwegian Ministry of Health and Care Services, the Swiss Federal Office of Public Health, the Transnational Institute (TNI), and the International Drug Policy Consortium (IDPC).

The Forum, held under the ‘Chatham House Rule’ in order to facilitate openness, sought to build upon the series of high-profile Brandenburg Forums on Drugs and Development Policies held in Germany since 2016 – providing a trusted space for important discussion and debate to strengthen the drug policy focus within the key health and human rights bodies in Geneva. The online nature of the Forum allowed the co-hosts to bring together a diverse group of 72 participants (38 women and 34 men) from around the world. This included representatives from the United Nations (UN) Office of the High Commissioner for Human Rights (OHCHR), the World Health Organisation (WHO), the International Narcotics Control Board (INCB), the UN Human Rights Committee, the UN Working Group on Arbitrary Detention, the UN Development Programme (UNDP), the UN Office on Drugs and Crime (UNODC), and the Joint UN Programme on HIV/AIDS (UNAIDS). Furthermore, there were representatives from other intergovernmental bodies, a number of experts from relevant civil society and community-led organisations, and 38 government officials from 14 countries (Albania, Argentina, Finland, France, Germany, Jamaica, Mexico, the Netherlands, Norway, Portugal, Sweden, Switzerland, Thailand and Uruguay).

The event began with warm welcomes from Swiss Ambassador H.E. Felix Baumann the Federal Drug Commissioner of Germany Daniela Ludwig MP, and senior officials from the Governments of Norway and the Netherlands. Ambassador Baumann reiterated Switzerland’s belief that the multifaceted world drug situation “cannot be discussed without its health and human rights aspects”, and highlighted the importance of cooperation between UN entities – especially in light of the UN system common position on drug-related matters4 and the 2030 Agenda for Sustainable Development.5 The Federal Drug Commissioner of Germany further highlighted the International Guidelines on Human Rights and Drug Policy6 (whose development was supported by GPDPD and the Swiss Government as well as UNDP) and its reference in the European Union Drug Strategy 2021-20257 (adopted under the German Presidency of the EU Council) as sending out a “strong signal to those violating fundamental human rights” in the name of drug control. Several participants underlined how the COVID-19 pandemic has put a magnifying glass on different societal problems we face.

1st Brandenburg Forum (BBF) in Geneva "Building bridges between the drug policy and human rights regimes of the United Nations"

The so-called war on drugs has resulted in a large and disproportionate increase in detention and imprisonment for drug-related offences. Some States have gone well beyond what is required by the international drug control treaties in terms of criminalization and associated penalties, while others have demonstrated excessive zeal in applying the criminalization provisions of those treaties. These disproportionate actions have frequently resulted in widespread human rights violations leading to increased arbitrary detention. Association of the military with drug control efforts has aggravated the situation in several States and has frequently resulted in more and worse human rights violations and punitive outcomes that have not proven effective in reducing the incidence of drug-related offences. The war on drugs has also generated a culture of corruption within law enforcement bodies, particularly regarding payments made to avoid arrest or to affect the outcome of judicial proceedings. States that provide financial or technical assistance to other States, including for drug enforcement operations, should ensure that their assistance does not contribute to human rights violations.

Arbitrary detention relating to drug policies - Study of the UN Working Group on Arbitrary Detention

The Global AIDS Strategy 2021-2026 recognizes that ending inequalities is essential to ending AIDS. Since 2010, the global AIDS response has made remarkable progress—tripling the number of people on ARV treatment and reducing deaths by 39%. But globally, only 26 countries are on track to achieve the goal of a 90% reduction in AIDS-related mortality by 2030 and only 23 countries are on track to reduce new HIV infections by 90%. Most countries in the world did not achieve the 90-90-90 treatment goals by 2020.

At the High-Level Meeting on HIV/AIDS (June 8-10, 2021), UN member states will recommit to the goal of ending AIDS by 2030. The Political Declaration is expected to recognize the central role that inequalities, stigma and discrimination, and violence play in fueling the HIV pandemic and the necessity of reforming laws and policies that drive discrimination and undermine access to HIV prevention and treatment.

The Political Declaration follows on UNAIDS’ release of the Global AIDS Strategy 2021-2026: End Inequalities. End AIDS. At the core of the strategy, an ambitious new set of targets, the 10-10-10 targets, call on countries to repeal punitive laws/policies that target key populations and to implement supportive laws/policies that combat stigma, discrimination, and gender-based violence.

These targets will not be achieved without transparency, evidence, and accountability—transparency around the laws/policies that countries have in place, evidence to show why policy change is necessary and beneficial, and advocacy to hold governments accountable for acting on their commitments and achieving the 10-10-10 targets.

Publications