Elsevier

The Lancet

Volume 376, Issue 9740, 14–20 August 2010, Pages 551-563
The Lancet

Series
Time to act: a call for comprehensive responses to HIV in people who use drugs

https://doi.org/10.1016/S0140-6736(10)60928-2Get rights and content

Summary

The published work on HIV in people who use drugs shows that the global burden of HIV infection in this group can be reduced. Concerted action by governments, multilateral organisations, health systems, and individuals could lead to enormous benefits for families, communities, and societies. We review the evidence and identify synergies between biomedical science, public health, and human rights. Cost-effective interventions, including needle and syringe exchange programmes, opioid substitution therapy, and expanded access to HIV treatment and care, are supported on public health and human rights grounds; however, only around 10% of people who use drugs worldwide are being reached, and far too many are imprisoned for minor offences or detained without trial. To change this situation will take commitment, advocacy, and political courage to advance the action agenda. Failure to do so will exacerbate the spread of HIV infection, undermine treatment programmes, and continue to expand prison populations with patients in need of care.

Introduction

The war on drugs has failed. Policies of detention, forced treatment, and incarceration of people who use drugs have been unsuccessful. The global response to HIV/AIDS, however, in terms of research, scale-up of prevention, human rights of those affected, and access to antiretroviral treatment, is showing some remarkable success. But the response to the substantial component of the pandemic driven by substance use is one of the most frustrating aspects of the global HIV/AIDS crisis. Evidence has not played enough of a defining part in public health policy, and too many governments, criminal justice systems, and medical establishments discriminate against patients with drug dependency, restrict their rights, and use outmoded and discredited forms of treatment while limiting use of—or banning outright—evidence-based approaches.

The USA, the largest funder of HIV/AIDS treatment and research worldwide, maintained a ban on federal funding for needle and syringe programmes (NSPs) until 2009. Yet, there are few interventions for prevention of HIV infection that are simpler and less costly than are NSPs.1, 2 The effort to expand evidence-based treatment, specifically opioid substitution therapy (OST), to those addicted to heroin and other opioids, has floundered where it was, and is, needed most: in Russia, parts of central Asia, and the Commonwealth of Independent States.3, 4

The reports in this Series draw from multidisciplinary published works promoting actions that individuals, communities, health-care systems, governments, and multilateral organisations can take to substantially reduce the global burden of HIV infection in people who use drugs.3, 4, 5, 6, 7, 8 Encouragingly, there are synergies between biomedical science, public health, and human rights. The right things to do to limit spread of disease are also the right things to do to protect human rights. Cost-effective actions are also ethically justified—eg, provision of outpatient OST for drug-dependent patients, as opposed to incarceration or denying them access to antiretroviral treatment (ART) because of discriminatory policies and practices.5, 8 The evidence confirms that a massive global scale-up of proven interventions, including the combination of NSPs, OST, and ART, is needed.4 High coverage of combined interventions sustained over time will be necessary to achieve lasting gains in prevention of HIV infection in people who use drugs.4 These interventions need to be tailored to country-specific and outbreak-specific contexts to have a maximum impact, as shown by Strathdee and colleagues.5 For many countries, this approach will require an invigorated country-specific research agenda to much better characterise HIV epidemics in people who use drugs (panel 1). The HIV response also needs to include universal access to evidence-based treatment for drug dependency.3 This treatment is a fundamental component of the right to health and an urgent public health priority. And, as Jürgens and colleagues8 point out, the right to health framework places a legal obligation on all countries to have and to implement effective and comprehensive harm-reduction programmes and policies.9

Key messages

  • Expansion of country-specific research and surveillance strategies is needed to give governments better and more strategic information about their drug-related epidemics.

  • HIV epidemics in people who use drugs can be largely controlled and their harms mitigated with currently available strategies. What is needed is massive scale-up of combination prevention, treatment, and care. In opioid-driven epidemics, this approach includes an essential minimum package of safe injection programmes, opioid substitution therapy, and antiretroviral treatment.

  • Universal access to evidence-based treatment for drug use is a fundamental right to health and an urgent public health priority.

  • Effective and comprehensive national harm-reduction policies, programmes, and services are essential to countries meeting their legal obligation to realise the right to health. High-income countries need to provide more than essential services. Pilot programmes are no longer sufficient.

  • The dangers of inaction in meeting the needs of people who use drugs include continuing spread of HIV infection in new populations and regions, increased complexity of HIV-1 epidemics at molecular levels, decreased access to opioids for pain management and palliative care, and the human, family, health, and social costs of mass incarceration and detention.

  • Expanded action and advocacy by health professionals on behalf of people who use drugs are urgently needed in both health-care and criminal justice sectors. Health professionals should not be complicit in programmes and policies that have no evidence base or that violate human rights. The voice of people who use drugs themselves needs to be heard at all levels, from service delivery to policy decision making.

  • Reform of justice systems is part of harm reduction: we call for decriminalisation of drug users, due legal processes, and access to health services for people who use drugs in all forms of prison and detention.

Commitment, advocacy, and political courage are needed to advance the action agenda described in this report. The evidence clearly shows that inaction will exacerbate the spread of HIV infection, undermine access to HIV prevention and ART programmes, continue to swell prison populations with patients in need of care, and result in abuses of human rights.

Section snippets

The scale and scope of the epidemic

The Reference Group to the UN on HIV and Injecting Drug Use estimated that worldwide around 15·9 million people (range 11·0–21·2 million) were injecting drug users (IDUs) in 2007.10 Figure 1 shows 2010 data for global estimated numbers of people who inject drugs by region, and HIV prevalence in people who inject drugs. Injecting drug use and associated HIV and hepatitis C virus (HCV) infections have been reported in nearly all UN member states, and across all income levels. People who use but

Continuing spread of HIV infection

In settings in which OST and NSPs are unavailable or illegal and drug-dependent people are treated as criminals, the consequences of inaction are high. First is the continuing spread of HIV infection. Secondary exposures for the sexual partners of drug users also need to be accounted for in this cost. In Russia, where OST is banned, transmission of HIV from predominantly male IDUs to female sex partners seems to account for a substantial component of the reported rise in HIV infections in women.

Changing the risk environment

In the first report in this Series, Strathdee and colleagues5 explored the risk environment for people who use drugs in three very different contexts: the cities of Odessa (Ukraine), Karachi (Pakistan), and Nairobi (Kenya). Their findings show that understanding risks of HIV infection in drug users must go beyond the individual and assess structural and environmental factors that shape individual risk practices and vulnerabilities to HIV infection. This broader risk environment framework

Making changes happen

There is an ambitious but achievable agenda that could save the lives of people who use drugs, prevent HIV infections, reduce the social harms of substance use, protect human rights, and save money (panel 4). How will it be implemented and by whom?

Conclusions

To realise the goals called for in this Series on HIV in people who use drugs, we need to go beyond public health approaches alone. If drug control sectors and law enforcement are not a part of new approaches, then harm-reduction programmes will be closed, substitution clinics will stay sparsely attended, and ART and preventive interventions will have a low uptake by drug users. But drug control sectors and law enforcement constitute one domain of global HIV management for which there is a

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