Drug Decriminalisation Holds the Key to Ending AIDS Among People Who Use Drugs, UN Guidance and Global Coalitions Argue
Key Insights
A new UN guidance note, developed with UNAIDS (search), UNDP, and INPUD, asserts that decriminalising drug use and possession for personal use is essential to ending HIV among people who use drugs.
The guidance reviews global models of decriminalisation, highlighting that combining decriminalisation with harm reduction strategies improves HIV outcomes and reduces transmission rates.
South Africa's newly formed Vusubuntu Decriminalisation Coalition (search) is launching on 26 June to push for an end to the criminalisation of personal drug use, citing collapsing harm reduction infrastructure and an HIV crisis.
A landmark guidance note from the United Nations argues that decriminalisation of drug use and possession for personal use is fundamental to ending the AIDS epidemic among people who use drugs. The resource, developed in partnership with UNAIDS (search), the United Nations Development Programme (search) (UNDP), and the International Network of People who Use Drugs (search) (INPUD), synthesises lessons from countries that have adopted various decriminalisation models and provides key principles for effective, rights-based reform.
The guidance note, titled Decriminalization of drug use in the context of HIV: a guidance note, pulls together evidence demonstrating that punitive drug control laws, policies, and policing practices act as barriers to healthcare, deterring people from accessing harm reduction services and carrying harm reduction materials. This punitive environment, the authors note, encourages rushed drug preparation and administration, resulting in more injuries, more sharing of needles, more transmission of HIV and viral hepatitis (search), and more drug-related deaths.
"Ending criminalisation protects health," write Mat Southwell and Alexei Lakhov, both former harm reduction managers and previous Executive Directors of the European Network of People who Use Drugs (EuroNPUD), in an analysis published by Drug Science. They highlight that sustained community advocacy has resulted in the Global AIDS Strategy 2021–2026 and the forthcoming 2026–2031 strategy, which includes bold targets for affected communities to be directly involved in HIV prevention, testing, treatment, and advocacy.
Global progress and the role of community leadership
Over 15 years, UNAIDS (search) has recognised the importance of repealing laws targeting people who use drugs. This growing focus on ending criminalisation to end AIDS has already led 39 countries to adopt decriminalisation, although the forms and definitions vary significantly. The Global AIDS Strategy includes a specific target that by 2025, only 13 countries will still have laws criminalising the possession of small amounts of drugs.
Importantly, UNAIDS (search) and the World Health Organization recognise that when decriminalisation of drug use and possession for personal use is combined with harm reduction strategies, people who use drugs have improved HIV and other health outcomes, are supported to engage in prevention and treatment services, and this reduces HIV transmission rates.
The central role of INPUD in gathering learning from the wider drug user community to inform the guidance note illustrates how global decision-making is increasingly embracing the testimony and experience of people who use drugs. In 2010, INPUD launched the Drug User Peace Initiative to call for an end to the war on drugs, arguing that the war on drugs has been waged against people who use drugs, driving them underground, away from services, and into harmful drug-taking practices.
The UK: a cautionary tale of retreat from harm reduction
The UK once exemplified a pragmatic, evidence-based response to HIV among people who inject drugs. In 1986, early data from Edinburgh suggested that HIV was already widespread among people who inject drugs in the UK. Politicians feared that people who inject drugs would become a "bridge" for HIV to spread through their sexual partners into the general population. This fear drove the Conservative Government to fund a national needle and syringe programme (NSP) pilot with 15 drug services in England and Scotland.
The Advisory Council for the Misuse of Drugs (ACMD) established a foundational principle: "The spread of HIV is a greater danger to individual and public health than drug misuse." This underpinned the development of NSP and harm reduction, alongside the scale-up of opioid agonist maintenance therapies such as methadone and buprenorphine.
However, successive Westminster governments have moved away from the British Model and the principles of harm reduction. The result, according to Southwell and Lakhov, is the highest drug-related deaths in Europe, a new HIV outbreak among people who inject drugs in Glasgow in 2015, and the fracturing of the therapeutic alliance between people with opioid dependence and drug treatment providers. The Westminster government incentivised drug services to get users off drugs for six months, prioritising treatment exit over long-term support — a policy that likely contributed to increased drug-related deaths, reduced trust in services, and poorer engagement with HIV and hepatitis C prevention.
Russia's deepening crisis
Russia has long advocated for strict crackdowns on drugs, prohibiting opioid agonist maintenance treatment and using sweeping "foreign agents" and anti-propaganda laws to heavily restrict civil society, independent media, and human rights organisations. In 2021, Russia accounted for nearly 4% of new HIV infections worldwide — the highest share in the European region and the fifth highest globally. While Russia's HIV epidemic has historically been concentrated among key populations, in 2023, 16 regions of Russia reported that the proportion of pregnant women with HIV had exceeded 1%, the threshold considered suggestive of a generalised epidemic.
Russia led the opposition to the Global AIDS Strategy and its focus on public health, human rights, and communities. Drug user advocates in Russia are seen as foreign agitators threatening the nation state, and the country's war with Ukraine has further degraded the healthcare system.
Scotland's rights-based approach
In contrast, Scotland has embraced a drug policy founded on human rights and public health principles. In 2021, the Scottish Government published its Medication Assisted Treatment (MAT) standards to ensure immediate access to treatment with a range of options and the right to make informed choices. Scotland is also addressing the underlying determinants of health, including poverty reduction, racial justice, and the wider criminalisation of other key populations who also use drugs.
The Scottish Government has proposed decriminalising possession of all drugs for personal use to tackle one of Europe's highest overdose death rates. The barrier to progress remains the Westminster Government's continued commitment to prohibition. The Scottish Drugs Forum has supported a rolling dialogue with people who use drugs, gathering their views and strengthening the capacity of people with living experience to contribute to drug policy development.
South Africa's new coalition seizes the moment
On 26 June — celebrated worldwide as International Support. Don't Punish Day — the Vusubuntu Decriminalisation Coalition (search) will formally launch in Tshwane, Pretoria, with a simple demand: end the criminalisation of drug use in South Africa. The coalition's aims are unambiguous: "A South Africa which is safe, healthy, and inclusive. A society where no person is criminalised for their drug use."
"If you are using drugs in South Africa, you are almost not considered to be human," said Phanini Lebise, a member of Vusubuntu's steering committee. "You are a drug user before anything else."
South Africa's harm reduction services have been severely impacted by the Trump administration's cuts to international aid. In the midst of this, a coalition of advocates, legal experts, and people who use drugs has been building toward this landmark moment. The coalition proposes replacing the current punitive approach with drug policy "rooted in compassion, evidence, health, human rights, and social justice."
Klaas Mtshweni, a National leader of the South African National AIDS Council Civil Society Forum's sub-Sector for People Who Use Drugs, noted that the country's sex worker and LGBTQ communities have advanced their rights over decades, but people who use drugs have been left behind. "We've been standing to the side," Mtshweni said. "Now it's our time."
The coalition is drawing on existing government documents that support decriminalisation, including South Africa's draft National Drug Master Plan 2026-2031 and the National Strategic Plan on HIV, TB and STIs 2023-2028. South Africa's model of cannabis decriminalisation — with the Cannabis for Private Purposes Act signed into law by President Cyril Ramaphosa in May 2024 — also provides cautious hope.
Even law enforcement agencies are keen for change, according to Charity Monareng, Executive Director of SSDP International and spokesperson for the coalition's steering committee. "The perception we've gotten from law enforcement officers is frustration. Mostly they're arresting the same people, it's a vicious cycle," she said. "It achieves nothing."
Reasons for hope
The UN's new drugs and HIV Guidance Note represents a practical review of evidence from countries that have attempted decriminalisation. No country has achieved a perfect model, but important lessons have been learned that can inform other countries' development of decriminalisation driven by human rights and public health principles.
Critically, the guidance emphasises that people who use drugs should be supported and resourced to meaningfully participate in the development, implementation, and monitoring of decriminalisation. This is key to ensuring that future models of drug policy reform do not repeat the mistakes of criminalisation.
"I know it's a long shot," Lebise admitted of South Africa's decriminalisation push, "but it's possible."