The U.S has endorsed a global HIV prevention strategy for the UN that urges access to sterile syringes and respect for the human rights of drug users.  The endorsement, which advocates said was both suprising and encouraging, came at a meeting of the program coordinating board of the Joint United Nations Programme on HIV/AIDS (UNAIDS) that convened in Geneva last week.

The U.S. has been pushing UN agencies to withdraw their support for syringe exchange and harm reduction since November 2004 when it urged the UN Office on Drugs and Crime to remove reference to harm reduction and syringe exchange from its materials. The U.S. continued its pressure in the lead up to the June 27-29 meeting of the UNAIDS board, insisting that references to sterile syringes from the document meant to set UNAIDS strategy on HIV/AIDS prevention. While virtually all other member states opposed this recommendation, the U.S. is one of the largest donors to UNAIDS and is therefore very influential.

HIV/AIDS prevention advocates fought back. Prior to the meeting, over 100 organizations submitted a sign-on letter to U.S. Global AIDS Coordinator Ambassador Randall Tobias asking that the U.S. accurately represent the public health consensus in support of syringe exchange programs. Member states other than the U.S. attending the UN meeting suggested that a prevention strategy that removed access to sterile syringes was “immoral” and “unethical.” Congressman Henry Waxman (D-CA) sent a letter to Secretary of State Condoleezza Rice urging that the U.S. base prevention policy on evidence rather than ideology, and the New York Times published an editorial on the first day of the meeting that called the U.S. approach "breathtakingly dangerous."

Following this concerted effort, in the final hours of the meeting the U.S. reversed itself and agreed to language in support of harm reduction and sterile injection equipment. "While it's hard to know what lever moved the U.S., it's clear that the hard work of AIDS activists, human rights groups, and country delegates themselves didn't hurt," said Daniel Wolfe, deputy director of Open Society Institute's International Harm Reduction Development Program and one of those advocating for inclusion of language on sterile injection equipment.

Whatever the effort that finally tipped the balance, the U.S. endorsement is crucial to combating injection-driven HIV epidemics in Russia, China and other parts of Asia. Wolfe says, "If the U.S. had succeeded in removing language about clean needles, it would have sent a signal that this approach was not a priority at precisely the moment when it is most badly needed."

The new policy outlines a list of "Essential Programmatic Actions for HIV Prevention" which includes using a harm reduction approach to reduce transmission among injection drug users by:

...developing a comprehensive, integrated and effective system of measures that consists of the full range of treatment options, (notably drug substitution treatment) and the implementation of harm reduction measures (through, among others, peer outreach to injecting drug users, and sterile needle and syringe programmes), voluntary confidential HIV counselling and testing, prevention of sexual transmission of HIV among drug users (including condoms and prevention and treatment for sexually transmitted infections), access to primary healthcare, and access to antiretroviral therapy. Such an approach must be based on promoting, protecting and respecting the human rights of drug users.

Wolfe points out that while having this language stricken would have been a serious setback, "It remains to be seen how this largely rhetorical commitment translates into programs and services."

In another stride forward for HIV/AIDS prevention that took place just before the PCB meeting, the World Health Organization added methadone and buprenorphine to its List of Essential Medicines. Both drugs are used in substitution therapy for people who use heroin, and their inclusion on the list means they are recommended for basic use by health programs worldwide. Easier access to methadone and buprenorphine will be another tool for countries facing rising rates of HIV transmission through injection drug use.