It is 50 years since the June 18, 1971 address by US President Richard Nixon that publicised the US administration's war on drugs. Nixon declared that drug abuse was “America's public enemy number one”. Despite Nixon mentioning “rehabilitation, research, and education” in his speech, the war on drugs has been an offensive, with military interventions, soaring arrest rates, and aggressive sentencing. The USA has borne a huge cost, both financially and socially, with those most marginalised and vulnerable shouldering the largest burden. Five decades in, and despite multiple administration changes, no sign of victory can be seen. Drug use flourishes, with 13·0% (35·8 million) of Americans aged 12 years or older in 2019 reporting they had used an illicit drug in the preceding month, as revealed by the National Survey on Drug Use and Health. The same year saw 70 630 deaths due to drug overdose, with 49 860 involving opioids (of which 14 139 were due to prescription opioids).

Although HIV was unknown at the time of Nixon's speech, the fate of the war on drugs and the HIV epidemic are intertwined. 186 500 of the 1·2 million people with HIV in the USA are believed to have acquired the virus through injection drug use. Despite the USA seeing an overall fall in HIV diagnoses over the past 5 years, infections due to injection drug use are on the rise. If the ambitious target of ending HIV in the USA by 2030 is to be reached the needs of injection drug users will be a key part of the strategy.

The effects of the war on drugs are not confined to the USA, and injection drug users face stigma and criminalisation worldwide. Globally, around one in eight people who inject drugs are living with HIV, and injection drug users are 29 times more likely than non-users to acquire HIV. In 2019, as shown in the new UNAIDS report Global Commitments, Local Action, 10% of new infections worldwide were in those who inject drugs. Many of these infections could have been prevented if the war on drugs had not contributed to an environment hostile (both politically and socially) to injection drug users. Some regions are hit harder than others: in eastern and central Asia 48% of new HIV infections are linked to injection drug use. A Feature in this issue of The Lancet HIV from Ed Holt explores the role softening drug laws in this region could have on HIV. A linked Profile highlights the work of Positive Movement, a Belarusian organisation, in providing advocacy, support, and treatment to people living with HIV who inject drugs in Belarus.The tools to prevent harms, including HIV acquisition, in people who inject drugs are backed by a wealth of evidence. A refusal to implement evidence-based strategies is not only morally wrong but an economically poor decision—in the USA every dollar spent on syringe services programmes is estimated to save US$6·38–7·58. However, The Global State of Harm Reduction 2020 report by Harm Reduction International paints a picture of worsening implementation of harm reduction measures. The number of countries with needle and syringe programmes remains stable, and the number in which medications for opioid use disorder are available has decreased.With the new administration of President Joe Biden, there is a chance for a fresh approach to the war on drugs. However, Biden's record on these issues is not encouraging and the initial signs are mixed. The priorities of the drug control policy for the new administration's first year encouragingly include expanding access to evidence-based treatment, enhancing harm-reduction efforts, and expanding access to recovery support services. However, local policies as well as federal will have to change. News of the recent vote by government officials in Scott County, IN, USA, to close their syringe exchange despite support from law enforcement, health workers, and community members is dispiriting. If the value of a service, vital in helping to contain an HIV outbreak in 2014–15 that led to over 200 HIV infections, is not recognised then the scale of the problem is clear. Work by Gregg Gonsalves and Forrest Crawford, published in The Lancet HIV in 2018, indicated that if the region had had services such as a syringe exchange in 2011 the number of HIV infections would have been reduced to ten or fewer.The war on drugs must end. Our previous Editorial on the topic highlighted Portugal as an example that other countries should follow. Decriminalisation of personal drug use, coupled with increased resources for treatment and harm reduction, alongside wider initiatives to reduce poverty, and improve access to health care, could transform the lives of those affected. This transformation might finally be something worth fighting for.Article InfoPublication HistoryIdentification

DOI: https://doi.org/10.1016/S2352-3018(21)00130-2

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