Internationally, there is a growing understanding and acceptance that policy approaches to personal drug use which rely on the punishment of the individual cause avoidable harms and need to change. A number of evidence-based policy options are available that offer opportunities to improve outcomes for public health and reduce drug-related harm to people who use drugs and their communities, and thereby contribute to reducing social iniquities. One of these policy options is the decriminalisation of drug offences related to personal use (hereinafter, ‘decriminalisation’). Across the globe, a number of jurisdictions have implemented some form of decriminalisation. There is equally a lot of work focused on bringing about progressive change in this policy space ongoing around the world.

The Ana Liffey Drug Project (ALDP), supported by the Global Drug Policy Program of the Open Society Foundations (OSF), invited some advocates for decriminalisation from around Europe to join a two-day meeting in February 2020. The meeting took place in Dunboyne, Ireland, and brought together delegates to share their experiences in advocating for decriminalisation in their own countries and to benefit from the insights of others.

This paper provides some key insights from this event, and from conversations which followed it, with largely the same group of advocates. At its core, this paper has a peer-to-peer focus. The target audience is primarily people who are advocating for decriminalisation in their own jurisdictions, or who are considering doing so. Public health, community safety and criminal justice stakeholders more generally may also find it of interest. The aim is to provide insights from ‘in the field’, sharing the views and experiences of people actively working on advocacy projects related to decriminalisation. It does not purport to be a full or academic treatment of the issue – rather, it is intended to provide insights that can help advocates frame and focus their work.

Decriminalisation Insights for Advocates

Key populations and their sexual partners have higher HIV prevalence than the general population and 62% of global new HIV infections are amongst this group. UN agencies including UNAIDS, WHO, UNODC, UNDP, as well as the Global Fund, PEPFAR, bilateral donors and private foundations, such as the Bill and Melinda Gates Foundation recognize that effective and evidence-based HIV response must focus on key populations who are most vulnerable to HIV transmission. For example, in Pakistan, there is an estimated 37,173 – 111,330 number of people who inject drugs, with a HIV prevalence rate of 38.4%, a mere 4.3% of which are virally suppressed, and low HIV prevention coverage of 29%. In Ukraine, there are an estimated 319,500 people who inject drugs with a 19.1% - 22.6% HIV prevalence rate. In Nigeria, the number of people who inject drugs is estimated at 80,000, with 9.2% HIV prevalence rate.

People who use drugs are a population group disproportionately vulnerable to HIV and AIDS, and are often left out of HIV prevention and treatment services. Criminalisation, stigma and discrimination, including within health care settings, are some of the main barriers they face when accessing services. Accordingly, decriminalisation should be a core component of public health and HIV prevention responses. Moreover, policy makers often make political and moral judgements about who to prioritise in programmes. People who use drugs bear the brunt of these types of decision-making.

Imprisonment, arbitrary detention and compulsory forced rehabilitation is a reality for many people who inject drugs. UNAIDS estimates that 56-90% of people who inject drugs will be incarcerated at some stage during their life. Therefore, it is essential to promote harm reduction and provide services in closed settings as well as in the community.

Harm reduction interventions are evidence-based and have a proven record of effectiveness and cost-effectiveness in the fight against HIV. Additional benefits include a reduction in criminal activity related to the need to access drugs, and individual, family and community social and health benefits. The unit costs of harm reduction interventions are relatively low, making it good value for money at $100 - $1000 per HIV infection averted.

From Invisibility to Influence: The evolution of participation of people who use drugs in the Global Fund

Gender-based violence (GBV) is caused by systemic gender inequalities and encompasses all acts of physical, emotional, sexual and psychological violence perpetuated against a person due to their gender (UNHCR, 2020). It is estimated that 35% of women worldwide have experienced some form of physical and/or sexual violence by an intimate partner, or sexual violence perpetrated by a non-partner (WHO, 2013a). Prevalence is estimated to be higher in sub-Saharan Africa (Pack, L’Engle, Mwarogo, & Kingola, 2014).

Although a number of studies have investigated GBV, including both intimate and nonintimate partner violence in the general population and among sex workers, relatively few studies have investigated the experience of GBV among women who use drugs (WWUD). Data on the prevalence of GBV and its underlying factors among this vulnerable group therefore remains relatively sparse and anecdotal. Considering literature that has found links between intimate partner violence, substance use, sexual decision making and HIV/AIDS, there is a gap in evidence on vulnerable populations especially WWUD in sub-Saharan Africa. This study therefore seeks to explore the lived experiences of WWUD and their children in Kenya, in relation to different types of GBV; and structures that perpetuate GBV among this population.

Physical abuse intersected with psychological control and included demands to stay indoors, violence, humiliation e.g. tearing of clothes or destroying WWUD’s personal and other effects sometimes in front of a victim’s family or their children. The reasons ranged from stealing partner’s money or drugs, suspicion of unfaithfulness, stealing from clients, partner’s frustration at WWUD for not earning money from sex work, refusing partner selling household goods, and rejection of partner’s forceful demands for sex.

Physical abuse was aimed at ensuring control and dependence of partners. Psychological abuse took many forms including family isolation and feelings of diminished worth, and was normalised by WWUD. Children of WWUD also suffered psychological abuse through separation from their mothers and direct verbal abuse from others.

Understanding experiences of gender-based violence among women who use drugs (WWUD)

The former communist countries of Eastern Europe and Central Asia (EECA) are transition economies, attempting to manage rising healthcare costs whilst reforming their health systems. EECA is one of the few regions in the world where the incidence of Human Immunodeficiency Virus (HIV) is going up. Because of competing needs, public health interventions for HIV have been low on policymakers priority lists, with the allocation of domestic funds to scaling-up HIV prevention programmes falling short of demand.

Criminalisation of drug use and incarceration for drug-related offences are one of the main influences behind an increase in prison populations in EECA countries. Arresting and putting people who inject drugs (PWID) in prison is both expensive and associated with an increase in HIV infections. The funds allocated to incarcerating PWID massively outweigh those spent on prevention and treatment for this group. The stigma associated with drug use in EECA further hinders the expansion of HIV prevention programmes within mainstream public health.

In parts of Western Europe, evidenceinformed, properly scaled up, community-led harm reduction services exist, where criminal sanctions for individual use and possession of drugs are removed and human rights are respected.9 Such harm reduction approaches have helped decrease problems with drug use, reduce overcrowding in prisons and dramatically reduce the incidence of HIV in PWID.9 The case for addressing punitive criminalisation strategies and stigma associated with HIV in PWID in EECA is clear, yet progress towards decriminalisation remains slow.

This Economist Intelligence Unit (EIU) report aims to capture the attention of policy-makers in four study countries in the EECA region; Belarus, Kazakhstan, Kyrgyzstan and Russia to make the case for the cost effectiveness and health gains achieved when the criminalisation of drug use is reduced, harm reduction is scaled up and stigma and discrimination towards PWID and other vulnerable populations is reduced.

Drug control policies in Eastern Europe and Central Asia - The economic, health and social impact

Twenty years ago, as the AIDS pandemic rapidly spread across the world, the international community for the first time collectively set an ambitious target to halt and reverse the spread of HIV by 2015. When this was achieved, we set an even more ambitious goal in 2016— to end AIDS as a public health threat by 2030. The collective vision of UNAIDS underpins these targets: zero new HIV infections, zero discrimination, zero AIDS-related deaths.

Global solidarity and community resilience has saved millions of lives. But far more could have been done. Many of the inequalities that facilitated the spread of the AIDS pandemic are getting worse and continue to fan the spread of HIV in many parts of the world. COVID-19 has brought these inequalities to the forefront and exposed the fragility of the gains we have made. The resilience and experience of the HIV response in addressing inequalities that disproportionately affect the key populations and priority populations is critical to the once-in-a-generation opportunity to ‘build back better’ from COVID-19.

There is hope. The solutions exist. 40 years of experience in the HIV response has provided the evidence of what works. Some countries have reached control of their AIDS epidemics. We know how to end AIDS, and this is the Strategy to get us there.

End Inequalities. End AIDS. Global AIDS Strategy 2021-2026 is a bold new approach to use an inequalities lens to close the gaps that are preventing progress towards ending AIDS. The Global AIDS Strategy aims to reduce these inequalities that drive the AIDS epidemic and prioritize people who are not yet accessing life-saving HIV services. The Strategy sets out evidence-based priority actions and bold targets to get every country and every community on-track to end AIDS as a public health threat by 2030.

Global AIDS Strategy 2021-2026

Part II of this publication, focused on the harm reduction response, is available here.

In March 2020, the World Health Organization (WHO) characterised COVID-19 as a pandemic, prompting governments around the globe to declare a state of emergency and/or implement a wide variety of policies and programmes in order to curb outbreaks, minimise mortality rates, and maintain public safety and order. These include, but are not limited to, different forms of travel and/or movement restrictions (such as lockdowns and quarantine), closure of premises deemed non-essential, and restrictions on gatherings and/or events. Such measures have caused significant changes in public life, public services, governance, democracy and policymaking processes around the world – as well as having serious short- and long-term economic implications.

One additional impact of these measures is the disruption of various channels and dynamics of advocacy conducted by civil society organisations. Prior to the global pandemic, civil society organisations were already facing increasing constraints and shrinking space for advocacy. The COVID-19 pandemic has certainly accelerated this downward trend of intensifying repression, in some cases combined with various forms of disinformation, abuse of power and violence. Meanwhile, some civil society actors have been pushed to adapt their ways of working while remaining resilient as they face impacts such as increased workload and/or pressure (amid having less in-person interactions, working from home, and growing demand for services), uncertainty around financial and organisational sustainability, and health concerns, among others.

Aiming to better understand and support the network to respond to these emerging challenges, especially with regard to advocacy for drug policy reform centred on human rights and public health, the IDPC Secretariat initiated a process of documenting and analysing the experiences of civil society and governmental actors working in the context of the COVID-19 pandemic. This goes in line with the IDPC mandate to advocate for civil society inclusion in drug policy debates, as well as to support civil society, and our members in particular, in navigating this new policy landscape.

Innovation and resilience in times of crisis - Civil society advocacy for drug policy reform under the COVID-19 pandemic

By Jerome Evanno / Paroles Autour de la Santé (PAS)

Between 4000/6000 “problematic / precarious” drugs users (DU's), frequent at least a hundred open consumption scene (in Monrovia). There are between 10 to 20% of women, the average age is 32/36 years and it has been noted the presence of children. The main illegal drug consumed remains cannabis. However, we were able to observe and confirm a significant consumption of cocaine in the form of crack, heroin (white) smoked with aluminum foil (the most common way of use is smoking), and non-prescription drugs (tramadol, valium, diazepam, etc.). At first, it was easy to see that in Liberia, and more particularly the capital Monrovia, that interventions related to the use and abuse of drugs (from a global health point of view), will require a multisectoral and holistic approach. The analysis of the data collected revealed a strong will on the part of all stakeholders to reform the current law « obsolete and very repressive » and strong expectations and needs on the part of the DU's.

Regarding the recommendations, they have been classified into 5 parts. Firstly, addictology, it will be more precise to reflect on the implementation of a « national rehab center », a « therapeutic community », « capacity building » of medical staff (more specifically for health staff and prescribers), « promote the prescription of methadone and OST », and « create self-support groups and / or support groups ». Then, for the aspects of Harm Reduction, it's recommended to carry out a « community and participatory diagnosis » of the needs and assessments of the DUs, to create « adapted tools », « self-support groups » and to promote « socio-economic reintegration activities ». It will also promote the activities and the Harm Reduction approach during the next funding requests and more particularly with the Global Fund (GF) and PEPFAR.

Regarding health care, we must support and validate the relevance of the implementation of « specific services », « TB / HIV adapted services », « food activities », « mobile health care service » and give « primary medication » without forgeting the mental health approach. Regarding drug policy, the organization of a « symposium for NGO » (position paper, recommendations, etc.), « promote the West African drug model law », support a « technical group » and drug policies / advocacy / lawyers team, a better knowledge of the current law, purpose of « alternatives of incarceration », and fostering participation and « regional / international technical/High level/experts groups ». Finally, for the community approach, although transversal, it is recommended to strengthen them in capacities and promote empowerment and support the implementation of the first community based organization.

Community and contextual analysis on drug use and drugs policies in Liberia

Thailand presently has one of the highest prisoner-to-population ratios in the world (524 prisoners per 100,000 population in 2018), and the world’s highest share of female prisoners (14%). It also suffers from one of the highest rates of overcrowding, with over three prisoners for every available prison space. Upward of 40 prisoners may be housed in a single cell, with less than 1.2 square meters for each male inmate and 1.1 square meters for each female inmate.

The prison population has grown rapidly even as crime rates in Thailand have declined. Particularly in the time of COVID, overcrowding poses a threat to public health, and undermines rehabilitation efforts. According to interviews with the Ministry of Justice, each year Thailand spends around 12,000 million Thai Baht (or 380 million USD) on prison administration. Some 95% of the Department of Corrections budget is spent on food for the prisoners, salaries for the guards, and construction of new prisons, with only 1% for rehabilitation programs. About one-third of prisoners released from Thai prisons are reincarcerated within three years.

In addition to the traditional drivers of recidivism, such as unemployment, it appears that two legal standards could be key to Thailand’s prison overcrowding and the consequent lack of resources for rehabilitation: the threshold amount for the presumption of intent to sell methamphetamine and the threshold amount to qualify for diversion to treatment. Data supplied by the Department of Corrections show:

• 80% of Thailand’s prisoners are incarcerated for drug-related offences;
• 78% of drug-related offenders were convicted for offences related to yaba (methamphetaminetablets); and
• 76% of these drug-related offenders were convicted for possession with intent to sell.

Research on the causes of recidivism in Thailand

When Mexico’s drug cartels forced Colombian traffickers out of the US cocaine market, they seized control of the most coveted prize in the global drug trade. But the smartest traffickers soon began to turn elsewhere, to a market where the profits were higher, the risks were lower and the potential for growth was immense. They turned to Europe.

Today, Europe is arguably the most attractive cocaine market in the world, and its size and importance only continues to grow. This series, which is the product of field work and investigations over two years in more than 10 countries in Latin America, the Caribbean and Europe, traces the evolution of the European cocaine trade and the Latin American and European criminal networks that have shaped it.

The cocaine pipeline to Europe

By Alexander Söderholm, PhD Candidate at the London School of Economics and Political Science

The disruption caused by the COVID19 pandemic has exposed the health inequities within our societies, and particularly in prisons. By February 2021, at least 504,000 people deprived of liberty had tested positive for COVID19 -approximately a 4.5% of the global prison population. This resulted in a minimum of 3,800 deaths, though this is likely to be an underestimate as many countries lack testing equipment within prisons. Across the world, our overcrowded prison systems have failed to protect the life and health of people deprived of liberty.

Through four case studies that focus on the response to the pandemic in Colombia, Indonesia, Ireland, and Kenya, this briefing, launched by IDPC together with Harm Reduction International, Penal Reform International, LBH Masyarakat, and Reprieve, draws several lessons from this still ongoing crisis.

At the outset of the pandemic, a number of countries committed to reduce the number of people in prison in order to prevent the spread of the virus. However, in many cases decongestion measures have arbitrarily excluded people detained for certain drug offences.

Many countries that implemented de­congestion measures simultaneously failed to halt the disproportionate imprison­ment of people for drug offences, thus undermining attempts to reduce prison overcrowding.

In most cases, states responded to the pandemic by isolating prisons from the community. As a result, people deprived of liberty have been unable to access the most basic legal, health, and drug services. In many countries, this also means that incarcerated people cannot receive the food, clothes, and money regularly provided by their families.

Before COVID19, there was already a dramatic lack of appropriate drug treatment and harm reduction services in prisons. Even were such ser­vices existed, incarcerated people have ex­perienced serious restrictions in accessing them during the pandemic.

Community integration programmes have failed to support people released from prison dur­ing the COVID-19 pandemic. Upon release, formerly incarcerated people have faced severe challenges, including exclusion from the formal economy, social stigma, and exploitation.

Prisons and COVID-19: Lessons from an ongoing crisis

By Sandhya Kajeepeta et al. / The Lancet

Mass incarceration is associated with widespread conse­ quences for community health, some of which extend beyond people who are and have been incarcerated and their immediate networks. Residents of neighbourhoods with high rates of prison incarceration have a higher risk of major depressive disorder, generalised anxiety disorder, dyslipidaemia, and metabolic syndrome than do residents of neighbourhoods with low prison incarceration rates. Nosrati and colleagues found that a standard devia­ tion increase in the rate of county jail admissions was associated with a 2% increase in county­level mortality from drug use disorder. We previously found that an increase from the first to the second quartile of within­ county rates of jail incarceration was associated with a 3% increase in the all­cause mortality rate.

Jail incarceration in the USA operates as an institutional product of structural racism that disproportionately affects Black Americans. Black people are nearly four times more likely to be incarcerated in local jails than white people. Moreover, the US criminal legal system disproportion­ ately criminalises and punishes poor people. The health effects of community­level exposure to high rates of jail incarceration might contribute to and worsen existing racialised and class­based health disparities. For example, during the COVID­19 pandemic, jails exacerbated the spread of the virus in communities that were already at a disproportionately higher risk of infection.

Increases in rates of county jail incarceration are associated with subsequent increases in county all­cause mortality rates. However, all­cause mortality is a hetero­ geneous outcome that includes deaths caused by chronic diseases, injuries, and infectious diseases. Identification of the specific causes of death that drive the observed association can help to elucidate potential mechanisms. Furthermore, if the relationship between the rates of county jail incarceration and county mortality is causal and not merely a shared consequence of concentrated and racialised disadvantage, we would expect jail incarceration rates to influence deaths from different causes to differing degrees and via differing mechanisms.

Association between county jail incarceration and cause-specific county mortality in the USA, 1987–2017: A retrospective, longitudinal study

By Ashley Nellis - The Sentencing Project,

Before America’s era of mass incarceration took hold in the early 1970s, the number of individuals in prison was less than 200,000. Today, it’s 1.4 million; and more than 200,000 people are serving life sentences – one out of every seven in prison. More people are sentenced to life in prison in America than there were people in prison serving any sentence in 1970.

Nearly five times the number of people are now serving life sentences in the United States as were in 1984, a rate of growth that has outpaced even the sharp expansion of the overall prison population during this period.

The now commonplace use of life imprisonment contradicts research on effective public safety strategies, exacerbates already extreme racial injustices in the criminal justice system, and exemplifies the egregious consequences of mass incarceration.

In 2020, The Sentencing Project obtained official corrections data from all states and the Federal Bureau of Prisons to produce our 5th national census on life imprisonment.

One in 7 people in U.S. prisons is serving a life sentence, either life without parole (LWOP), life with parole (LWP) or virtual life (50 years or more), totaling 203,865 people;

The number of people serving life without parole — the most extreme type of life sentence — is higher than ever before, a 66% increase since our first census in 2003;

29 states had more people serving life in 2020 than just four years earlier;

30% of lifers are 55 years old or more, amounting to more than 61,417 people;

3,972 people serving life sentences have been convicted for a drug-related offense and 38% of these are in the federal prison system;

More than two-thirds of those serving life sentences are people of color;

One in 5 Black men in prison is serving a life sentence;

Latinx individuals comprise 16% of those serving life sentences;

One of every 15 women in prison is serving life;

Women serving LWOP increased 43%, compared to a 29% increase among men, between 2008 and 2020;

The population serving LWOP for crimes committed as youth is down 45% from its peak in 2016;

8,600 people nationwide are serving parole-eligible life or virtual life sentences for crimes committed as minors

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