「向毒品宣戰」與「對抗愛滋」是無法共存的

資料來源：刺胳針愛滋醫學期刊，www.thelancet.com/hiv Vol 6 May 2019

財團法人台灣紅絲帶基金會編譯

儘管在2010年至2017年間全世界愛滋感染的發生率下降了25％，聯合國愛滋病規劃署最近的一份報告中，強調在注射藥物者（people who inject drugs , PWID）當中愛滋日益嚴重的問題。

自2016年聯合國大會關於世界毒品問題的特別會議中，重申了對會員國在解決藥物使用導致公共衛生後果問題上的承諾以來，藥物注射者的健康結果幾乎沒有改善，藥物注射者當中的愛滋感染的發生率從2011年的1.2％上升到2017年的1.4％。藥物注射者也受到不成比例之愛滋負擔影響，約有12％的人感染了愛滋病毒。雖然預防愛滋傳播之介入措施存在於這個關鍵族群中，但是對藥物使用行為的罪刑化、懲罰性毒品政策、污名和邊緣化，嚴重地限制了全球各項服務的實施和採用。

清潔針頭和針具交換計畫，阿片類藥物替代治療，納洛酮（該藥物可以緩解攝入過量鴉片類藥物所造成的影響，納洛酮可以與鴉片類藥物混入同一藥品中，以減少誤用時中毒的風險），安全的注射室、抗反轉錄病毒藥物治療、以及暴露前預防投藥都可以預防在藥物注射者當中HIV的傳播。

但是，在全球範圍內僅有1％的注射藥癮者可以充分地接觸到針頭和針具清潔計畫和阿片類藥物替代療法。多數的國家一直在關於藥物使用上不願意或遲疑，能有除罪化和污名的安全環境當中，去全面實施減害計畫和提供足以獲得的愛滋防治服務。相反地，取而代之的是他們很大程度上依賴那些拒絕取得公共衛生介入措施的政策 – 例如禁止阿片類藥物替代療法（例如，俄羅斯）和限制針頭和針具交換計畫（例如，美國） – 以及以罪刑化的司法系統去解決注射藥癮者藥物的使用。

來自剌胳針愛滋病毒醫學期刊中Kora DeBeck和他的同事在系統評估上的證據，顯示出許多罪刑化的指標對注射藥癮者愛滋感染的預防和治療上有負面的影響 – 這些包括監禁、街道警務，阻止擁有用藥工具的法律或慣例、禁止或限制具有實證基礎的愛滋預防介入措施，以及國家藥物策略上針對藥物的使用採取懲罰性方法。

值得注意的是，鼓勵監禁的毒品政策針對非暴力的注射藥癮者增加了愛滋傳播的風險，由於針具的共用和抗反轉錄病毒藥物治療之中斷，在監獄的囚犯中反而有更高的風險。罪刑化不僅在服務實施上扮演障礙的角色，也是助長社會對注射藥癮者的污名和歧視，且阻礙可用資源的使用。

葡萄牙是少數幾個追求除罪化的國家之一，對於藥物使用問題上轉向公共衛生可以實現什麼樣的成果這是一個重要的例子。在2001年，葡萄牙對持有個人使用的藥物和藥物的使用予以除罪化，這些在現在完全都是行政違規。販毒則仍然會被起訴為刑事犯罪。儘管當時有除罪化的反對者預測藥物使用和毒品旅遊的增加，情況恰恰相反，隨著許多藥物類別使用上的減少。資源重定轉向為注射藥癮者提供治療計劃且轉向減害措施，也減少了與藥物有關的死亡率和疾病傳播。除罪化之前，葡萄牙在注射藥癮者當中的愛滋感染率是歐盟國家中最高的，但在1999年至2003年之間該族群新發病例減少了17％。而葡萄牙注射藥癮者中的愛滋新感染病例從2000年的907例下降至至2017年僅有18例。

在永續發展目標（the sustainable development goals , SDGs）的核心，是改善世界人口的健康和福祉。罪刑化藥物的使用和懲罰性的毒品政策與實現永續發展目標的目的背道而馳並危及2030永續發展目標設定之議程。例如，藥物政策與實現永續發展目標3「在所有年齡階段確保所有人健康的生活及促進其福祉」密不可分；以及在其相關次目標3.3和3.5，其中均涉及終結愛滋病流行、防治肝炎，和加強預防藥物濫用。各會員國應該好好的思量在進行所謂的向毒品宣戰和實現永續發展目標兩者之間的不匹配問題。

注射藥癮者中的HIV流行正在惡化，但是扭轉這種趨勢的方式及方法都是現存的。所缺乏的是在解決愛滋議題上公眾和政治上的意願，去接受注射藥癮者在藥物使用上的除罪化這至關緊要的一點。用強硬打擊犯罪言論和政策來迎合民粹主義情緒可能看似在政治上短期內的權宜之計，但只會對社會的健康和福祉這些政府所被要求之服務上造成長期的損傷。相反地政府必須制定尊重和保護這一弱勢易感族群之人權的藥物政策，同時優先考慮控制注射藥癮者中HIV傳播的公共衛生措施，並認知這些措施只會在安全、去污名的環境下才能真正起作用。

■剌胳針愛滋病毒醫學期刊

The war on drugs is incompatible with the fight against HIV

Despite a 25% reduction worldwide in the incidence of HIV between 2010 and 2017, a recent report from UNAIDS Highlights the growing problem of HIV among people who inject drugs (PWID). Since the 2016 UN General Assembly Special Session on the World Drug Problem, which reaffirmed member states’ commitment to addressing the public health consequences of drug use, there has been little improvement in the health outcomes of PWID. The incidence of HIV among PWID has risen from 1·2% in 2011 to 1·4% in 2017. PWID are also disproportionately affected by the burden of HIV, with about 12% infected with HIV. Although interventions exist that prevent HIV transmission in this key population, criminalisation of drug use, punitive drug policies, stigma, and marginalisation severely limit the implementation and uptake of services worldwide.

Needle and syringe programmes, opioid substitution therapy, naloxone, safe consumption rooms, antiretroviral therapy, and pre-exposure prophylaxis can all prevent the transmission of HIV among PWID. However, globally, only 1% of PWID have adequate access to needle and syringe programmes and opioid substitution therapy. Most countries have been reluctant to implement comprehensive harm reduction and HIV services that can be accessed in safe environments free of criminalisation and stigma associated with drug use, instead they rely in large part on policies that deny access to public health interventions— such as the banning of opioid substitution therapy (eg, Russia) and restriction of needle and syringe exchanges (eg, the USA)—and the criminal justice system to address injection drug use.

Evidence from a systematic review by Kora DeBeck and colleagues in The Lancet HIV showed that several criminalization indicators have a negative effect on HIV prevention and treatment in PWID—these include incarceration, street-level policing, laws or practices to deter possession of drug paraphernalia, prohibitions or restrictions on evidence-based HIV prevention interventions, and national drug strategies that take a punitive approach to drug use. Notably, drug policies that encourage the incarceration of non-violent PWID add to the risk of HIV transmission, which is higher among prison inmates owing to issues such as needle sharing and interruption of ART. Criminalisation not only acts as a barrier to service implementation, by promoting social stigma and discrimination against PWID, it also hampers access to services when they are available.

Portugal is one of the few countries to have pursued decriminalisation, and it stands as an important illustration of what can be achieved by shifting to a public health approach to drug use. In 2001, Portugal decriminalized drug possession for personal use, and drug use, which are now exclusively administrative violations. Drug trafficking is still prosecuted as a criminal offence. Despite predictions at the time of an increase in drug use and drug tourism by opponents of decriminalisation, the opposite happened with a decline in use of many drug categories. Resources redirected to provide treatment programmes for PWID and a shift to harm-reduction measures have reduced drug-related mortality and disease transmission. Before decriminalisation, Portugal had the highest rate of HIV among PWID in the EU, but between 1999 and 2003 there was a 17% reduction in new cases among this group. New cases of HIV among PWID in Portugal fell from 907 in 2000 to just 18 in 2017.

At the very centre of the sustainable development goals (SDGs) is improving the health and wellbeing of the world’s population. Criminalisation of drug use and punitive drug policies are counter to the aim of achieving the SDGs and jeopardise the SDG 2030 agenda. For example, drug policies are inextricably linked to the achievement of SDG 3 “ensure healthy lives and promote wellbeing for all at all ages” and its associated targets 3.3 and 3.5, which involve ending the HIV epidemic, combating hepatitis, and strengthening the prevention of substance abuse. Member states would do well to consider the mismatch between pursuing a so-called war on drugs and achieving the SDGs.

The HIV epidemic among PWID is getting worse, but the ways and means of reversing this trend exist. What is lacking is the public and political will to accept that decriminalisation of drug use among PWID is essential to tackling HIV. Pandering to populist sentiments with toughon- crime rhetoric and policies might seem politically expedient in the short term, but will only do long-term damage to the health and wellbeing of societies that governments are called on to serve. Governments must instead develop drug policies that respect and protect the human rights of this vulnerable population alongside prioritising public health measures to control HIV transmission among PWID, acknowledging that such measures will truly work only in safe, stigma-free environments.

■ The Lancet HIV  www.thelancet.com/hiv Vol 6 May 2019