Year of Publication: 2007 Principal Authors: Lawyers Collective HIV/AIDS Unit Designed and Printed by: Macro Graphics Pvt. Ltd. Disclaimer: This review was commissioned by the UNODC Regional Office for South Asia. The opinions expressed in this document do not necessarily represent the official policy of the United Nations Office on Drugs and Crime. The designations used do not imply the expression of any opinion whatsoever on the part of the United Nations concerning the legal status of any country, territory or area or of its authorities, frontiers or boundaries. This document has not been formally edited. i LEGAL AND POLICY CONCERNS RELATED TO IDU HARM REDUCTION IN SAARC COUNTRIES A REVIEW COMMISSIONED BY UNODC Prevention of Transmission of HIV among Drug Users in SAARC Countries TD/RAS/03/H13 Review by Lawyers Collective HIV/AIDS Unit Supported by i ii TABLE OF CONTENTS LIST OF ABBREVIATIONS V PREFACE VII FOREWORD VIII ACKNOWLEDGEMENTS X ABOUT THE REPORT XI I. HARM REDUCTION AND THE LAW 1 1. What Is Harm Reduction? 1 2. Components of Harm Reduction Services 2 3. Harm Reduction - Efficacy 7 4. The Interface between Law and Harm Reduction 9 5. Conclusion 15 II. INTERNATIONAL LEGAL FRAMEWORK 16 1. Injecting Drug Use Programs: Co-existence and Conflicts with 16 National Legislations 2. Contextualising National Legislations: International Narcotics Conventions 17 3. International Bodies 21 4. Other Relevant Documents 21 5. Conclusion 23 III. COUNTRY ANALYSIS 24 A. Bangladesh 24 1. Drug Use and HIV/AIDS: Risks and Vulnerabilities 24 2. Drug Use and HIV/AIDS: Law and Policy Framework 26 3. Drug Use and HIV/AIDS Harm Reduction Practices 34 iii B. Bhutan 39 1. Drug Use and HIV/AIDS: Risks and Vulnerabilities 39 2. Drug Use and HIV/AIDS: Law and Policy Framework 40 3. Drug Use and HIV/AIDS Harm Reduction Practices 49 C. India 51 1. Drug Use and HIV/AIDS: Risks and Vulnerabilities 51 2. Drug Use and HIV/AIDS: Law and Policy Framework 54 3. Drug Use and HIV/AIDS Harm Reduction Practices 66 D. Maldives 77 1. Drug Use and HIV/AIDS: Risks and Vulnerabilities 77 2. Drug Use and HIV/AIDS: Law and Policy Framework 79 3. Drug Use and HIV/AIDS Harm Reduction Practices 85 E. Nepal 87 1. Drug Use and HIV/AIDS: Risks and Vulnerabilities 87 2. Drug Use and HIV/AIDS: Law and Policy Framework 88 3. Drug Use and HIV/AIDS Harm Reduction Practices 96 F. Pakistan 101 1. Drug Use and HIV/AIDS: Risks and Vulnerabilities 101 2. Drug Use and HIV/AIDS: Law and Policy Framework 103 3. Drug Use and HIV/AIDS Harm Reduction Practices 113 G. Sri Lanka 119 1. Drug Use and HIV/AIDS: Risks and Vulnerabilities 119 2. Drug Use and HIV/AIDS: Law and Policy Framework 122 3. Drug Use and HIV/AIDS Harm Reduction Practices 128 IV. DISCUSSION 131 iv LIST OF ABBREVIATIONS AIDS Acquired Immune Deficiency Syndrome MOHFW Ministry of Health and Family Welfare AIIMS All India Institute of Medical Sciences MSJE Ministry of Social Justice and Empowerment ANF Anti Narcotics Force MSM Men having Sex with Men ART Anti-Retroviral Treatment NAC National AIDS Committee ARV Anti-Retroviral NACP National AIDS Control Program BCC Behaviour Change Communication NACO National AIDS Control Organization BDR Bangladesh Rifles NAPCP National AIDS Prevention and Control Policy BNCA Bhutan Narcotics Control Agency NASP National AIDS and STD Control Program CBN Central Bureau of Narcotics NCB Narcotics Control Bureau CBO Community Based Organization NDPS Narcotic Drugs and Psychotropic Substances CCP Code of Civil Procedure NDPSSA Narcotic Drugs and Psychotropic Substances and CCrP Code of Criminal Procedure Substance Abuse CDDA Cosmetics Devices and Drugs Act NNCB National Narcotics Control Board CND Commission on Narcotic Drugs NASROB National Assessment of Situation and Responses CNSA Control of Narcotics Substances Act to Opiod/Opiate use in Bangladesh DADRP Drug Abuse Demand Reduction Project NCNCC Narcotics Control National Co-ordination DCB Drug Control Bureau Committee DCP Drug Control Programme NDCLEU Narcotic Drug Control Law Enforcement Unit DDA Department of Drug Administration NDDCB National Dangerous Drugs Control Board DGHS Directorate General of Health Services NGO Non Government Organization DIC Drop in Centre NIMHANS National Institute of Mental Health and DNC Department of Narcotics Control Neurological Sciences DOT Directly Observable Treatment NSEP Needle Syringe Exchange Programs DPH Department of Public Health NWFP North West Frontier Province DRC Demand Reduction Committee PIL Public Interest Litigation DUs Drug Users PIP Program Implementation Plan FATA Federally Administered Tribal Areas PNB Police Narcotic Bureau HCV Hepatitis C Viral PNCB Punjab Narcotics Control Board HIV Human Immunodeficiency Virus PODD Poisons Opium and Dangerous Drugs Act HSPS Health Sector Programme Support RIAC Rapid Intervention and Care Project ICCPR International Covenant on Civil and Political RRTCs Regional Resource Training Centres Rights SAARC South Asian Association for Regional ICESCR International Covenant on Economic, Social and Cooperation Cultural Rights SACS State AIDS Control Society IDU Injection Drug User SRC Supply Reduction Committee IEC Information Education and Communication STD Sexually Transmitted Diseases ILO International Labour Organization STI Sexually Transmitted Infections INCB International Narcotics Control Board TRC Treatment Review Committee INF International Nepal Fellowships UDHR Universal Declaration of Human Rights IPC Indian Penal Code UNAIDS Joint United Nations Programme on HIV/AIDS LAAM Levo Alpha Acetyl Methoadol UNDCP United Nations Drug Control Programme LTTE Liberation Tigers of Tamil Eelam UNGASS United Nations General Assembly MOHA Ministry of Home Affairs UNODC United Nations Office on Drugs and Crime MMC Methadone Maintenance Clinic VCT Voluntary Counselling and Testing MoE Ministry of Education WHO World Health Organisation v vi PREFACE AIDS is an extraordinary disease. As such, it requires an extraordinary response. In South Asia, the HIV epidemic is heterogeneous in nature. Bangladesh, Nepal and Pakistan have HIV epidemics that are primarily driven by injecting drug use. India — a country with one of the largest numbers of people living with HIV/AIDS — features an epidemic in its North Eastern region which is primarily driven by injecting drug use. Bhutan, the Maldives and Sri Lanka are countries with growing number of injecting drug users. The document you are holding in your hands examines whether the laws and policies currently in South Asia are adequate to meet the challenges posed by the threat of HIV/AIDS. UNODC has been a co-sponsor of the Joint United Nations Programme on AIDS (UNAIDS) since 1999. In 2005, the Programme Co-ordination Body of UNAIDS endorsed the comprehensive approach for prevention of transmission of HIV through injecting drug use in the UNAIDS policy position paper entitled “Intensifying HIV Prevention”. This comprehensive approach consists of a wide variety of measures, ranging from drug dependence treatment (including drug substitution treatment), outreach providing injecting drug users with information on risk reduction and referral to services, clean needles and syringes, and condoms, voluntary counselling and testing, treatment of STIs, antiretroviral therapy, and interventions for especially-at-risk populations such as prisoners and sex workers who inject drugs. The comprehensive package of measures also usually includes treatment instead of punishment for persons convicted of minor offenses. It does so because drug dependence treatment constitutes a humane, cost effective alternative, and because incarceration usually increases the risk of HIV transmission. A consistent body of evidence has established that comprehensive HIV prevention programmes which include needle syringe programmes and oral substitution as part of a comprehensive package reduce drug-related HIV risk behavior (such as needle sharing, unsafe injecting, and frequency of injection). Similarly, there is strong evidence that substitution treatment reduces criminal behavior and illicit opioid use. It also increases treatment retention and improves the overall health status of drug users infected with HIV. These are outcomes which we all seek to promote. I am confident that the findings of this review will help to build a policy environment in which public health decisions are taken on the basis both of the lessons learnt elsewhere and the cumulative weight of scientific evidence. Gary Lewis Representative Regional Office for South Asia vii FOREWORD Over the last decade or so, attempts have been made to understand social, economic, political and legal factors that determine health. This approach to health has seen increasing application in the context of the HIV/AIDS epidemic. Individual risk behaviors including injecting drug use are influenced by structural elements that include, inter alia, law, mechanisms for its enforcement and its application in Court. To illustrate, the likelihood of an injecting drug user (IDU) reusing contaminated needles to ‘fix a shot’ is greater where possession of injection paraphernalia can lead to arrest than in jurisdictions where he/she can procure a syringe without being apprehended by the police. Further, laws have a direct bearing on public health policy and programming. Certain effective interventions for reducing harm may not be permitted or closed down for ‘want’ of legal sanction. On the other hand, if facilitated by law, interventions can be initiated and scaled up to reduce individual vulnerability and promote public health. This is especially true for services like needle-syringe exchange that are crucial to break the chain of HIV transmission among IDUs. It is against this background that the review of legal and political concerns related to IDU Harm Reduction was commissioned by the United Nations Office on Drugs and Crime Regional Office for South Asia (UNODC ROSA) to the Lawyers Collective HIV/AIDS Unit (the Unit) for Project TD/RAS/03/H13 “Prevention of transmission of HIV among drug users in SAARC countries”, aimed at scaling up HIV interventions among (IDUs) and opiate users in the region. The research is aimed at examining the current legal and policy regime on drug use in SAARC countries i.e.