Improving coverage and scale-up of HIV prevention, treatment and care for injecting drug users: Moving the agenda forward
Article Outline
The significance of reaching adequate numbers of injection drug users (IDUs) with effective interventions has been universally accepted and reiterated by researchers, national and international agencies and drug user groups (UNAIDS, 2006; Vickerman, Hickman, Rhodes, & Watts, 2006). In recent years there has been some debate about how coverage should be defined, what an acceptable level of coverage should be, how it might vary with the intervention type, and how it can be measured (Sharma, Burrows, & Bluthenthal, 2007; UNAIDS, 2006). Progress has been made not only in strengthening the scientific underpinnings of what constitutes effective coverage but also in operationalising monitoring and evaluation systems that assist programme managers in tracking intervention coverage.
This Supplementary Issue on Coverage of Harm Reduction Programmes brings together the most recent research and practical programme efforts in setting and measuring coverage targets and indicators. Several previous papers by the Guest Editors (singly and together) noted a wide range of problems and misunderstandings based on different (though often unvoiced) interpretations of the term “coverage” (Aceijas, Hickman, Donoghoe, Burrows, & Stuikyte, 2007; Bluthenthal, Anderson, Flynn, & Kral, 2007; Bluthenthal, Ridgeway, et al., 2007; Burrows, 2005, Burrows, 2006, Sharma et al., 2007). In this issue, many of the problems identified in previous papers are described more fully and, in some cases, solutions are offered.
Significantly, this volume received papers for consideration not only from the developed world such as the United States of America (U.S.A.) but also from Myanmar, Bangladesh, Russia, the Ukraine, Pakistan, and Central Asia—signifying that coverage is no longer simply viewed from a research and academic perspective but has been absorbed into the discourse of harm reduction field activities and programming in a range of diverse resource and cultural settings. While academics and researchers have contributed greatly to conceptual and scientific progress around defining and measuring coverage, it would appear that the UN system as a whole, programme managers and skilled information technology experts are taking forward the development of tools to set targets and measure progress against them.
Sarang, Rhodes, and Platt (2008) report data from a multi-method study investigating access to needles and syringes in Moscow, Volvograd and Barnaul in the Russian Federation. Their analysis indicates that fewer than 7% of IDUs in these cities ever had any contact with needle syringe programmes (NSPs) as the vast majority used pharmacies for accessing injecting equipment. This underscores the need for HIV prevention coverage indicators to include measures of pharmacy-based syringe distribution rather than coverage by NSPs alone.
In Bangladesh, Reddy, Hoque, and Kelly (2008) show the value of an extensive and inclusive process for estimating the size of the national population of injecting drug users: “the fact that the estimates were done through a sub-committee of the National AIDS Committee at the bequest of the Ministry of Health and Family Welfare gives them official legitimacy in the country, and the involvement of implementing NGOs grounds them in reality at the field level. Inclusion of all the main stakeholders was a strategic way to balance the conflicting interests that often surround such estimates”. As they note, only with the consensus on a national population size for IDUs could coverage calculations be carried out. The authors describe the challenge of trying to estimate the number of safe injections provided for by Bangladeshi NSPs in the midst of constant switching between heroin smoking and opioid injecting.
Factors that lead to different rates of coverage are explored in Tempalski et al.'s (2008) examination of syringe coverage for heroin injection in 36 large metropolitan areas in the U.S.A. in which heroin is the dominant injected drug. The authors find that, despite the rapid growth in NSPs in the U.S.A. throughout the 1990s, only a small fraction of IDUs appear to have contact with a NSP; that is, whether IDUs have access to sterile syringes very much depends on where the drug users live. In addition, their analysis suggests that syringe coverage distribution and coverage increase the longer the NSP is in operation.
The authors also found that those metropolitan areas in the U.S.A. with the highest coverage by NSPs tended to be those with greater proportions of men who have sex with men (MSM): many gay and lesbian activist groups were among the first to start HIV interventions in the U.S.A. and ACT UP in particular established several of the earliest NSPs and provided crucial support to others (Bluthenthal, 1998). The authors find that this may provide additional evidence that grassroots activism plays an important role in programme implementation and successful NSP coverage. The authors also find strong evidence that government funding for NSPs contributes to better NSP coverage. Almost as important as these key factors are the findings that many other factors, hypothesized to be important in coverage, had an insignificant effect: these included, most remarkably, the level of opposition to syringe exchange (especially as shown by a hostile legal/regulatory environment) and a range of socio-economic and demographic measures.
Emmanuel and Fatima's (2008) analysis of data in Pakistan offers some initial estimates of harm reduction programme coverage. Current levels of harm reduction programme coverage may not prevent new epidemics from emerging or reversing the well established epidemics in sites such as Karachi. While almost 32% of IDUs in specified programme catchment areas had ever registered with a harm reduction programme, only 16.5% of IDUs report ever having utilized any services nation-wide.
In their commentaries, Gray and Hoffman (2008) and Baldwin, Boisen, and Power (2008) examine ways to track contact with interventions over time, as well as analyzing intervention contacts by sex, age and types of services delivered. Gray and Hoffman also describe the need to set targets for “sufficient coverage” rather than high coverage or universal access, arguing that most developing and transitional countries will find it difficult enough to provide coverage at the level needed to prevent or control a HIV epidemic, though universal access should remain a long-term goal.
What constitutes sufficient coverage to impact HIV epidemics among IDUs will continue to be examined and debated. Heimer (2008) offers a straightforward analysis of two NSPs in the U.S.A. that suggest that relatively low levels of regular contact or “regular reach” can have a substantial impact on AIDS case rates among IDUs. Heimer also provides guidance on assessing NSP coverage using three relatively accessible data sources: AIDS cases in a geographic area, number of syringes distributed during a time period, and total number of injections by IDUs during a time period. More research is required to determined the applicability of this metric to other IDU-related HIV epidemics, but this offering is nonetheless an important contribution to the continuing investigation and debate about coverage.
Finally, Donoghoe, Verster, Pervilhac, and Williams (2008) describe the recent development of a joint Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users, a collaboration between the Joint United Nations Programme on HIV/AIDS (UNAIDS), the United Nations Office on Drugs and Crime (UNODC), the World Health Organization (WHO) with national and international expertise. This guide serves to provide more consistent methods of measuring and comparing countries’ progress towards universal access and offers consensus as to which interventions should be included in a comprehensive package. It provides guidance on defining and estimating denominator populations and proposes a set of standard or core indicators to measure coverage, as well as indicative targets or benchmarks against which to measure progress towards universal access.
As these reports illustrate, the issue of harm reduction coverage is no less complicated than any of the other issues related to HIV prevention in developed and developing countries. That is, coverage touches on issues related to human rights and equity (the right of IDUs to have adequate coverage of HIV prevention and care interventions), science (how much coverage is required to reduce risk or to reduce infections), and politics (who decides whether enough coverage has been provided: the donor, the evaluator or the drug user client). While the reports in this special issue do not definitively address these concerns, they do add to a rapidly growing literature that is wrestling with the often competing impulses of best practices in public health, politics, human rights, and limited resources. These reports considered together provide useful guidance about how non-governmental agencies, governments, international donors, and public officials might want to proceed. In the following we identify five key lessons learned.
First, there is no one path to adequate harm reduction coverage. For instance, in Pakistan it was noted that the initiation of comprehensive in content, but limited in reach, harm reduction programmes appeared not to be forestalling rapidly expanding HIV transmission among IDUs there (Emmanuel & Fatima, 2008). Consideration of other venues for syringe distribution and HIV prevention education should be implemented including pharmacies—as illustrated by the Russian Federation case (Sarang et al., 2008).
Second, at present, we do not know what levels of coverage are required to prevent or reduce HIV epidemics among IDUs. The WHO has defined “coverage” in a manner that intrinsically links effectiveness with coverage—‘the proportion of the population in need of an intervention which has received an effective intervention’ (Hogarth, 1975, WHO, 2001). From several papers in this issue, it is clear that one of the key terms in this definition is “intervention”. An intervention is not effective if an injecting drug user receives one information leaflet, one needle and syringe, one dose of methadone etc. Coverage must include measures of regularity and/or duration to be useful, as Emmanuel and Fatima note in Pakistan.
On the other hand, as Heimer points out, NSPs that provide limited access to sterile syringes might still have a substantial impact on AIDS case rates among IDUs. More empirical research in developed and developing countries with more rigorous study designs will need to be conducted before we know what constitutes adequate harm reduction coverage. These studies will also need to consider the mix of syringe sources (NSPs, pharmacies, secondary exchange) and other harm reduction services (drug treatment, access to primary care including diagnosis and treatment of sexually transmitted infections among and from IDUs to their partners) as well as the situational mix amongst drug user characteristics, drug use preferences, and drug use settings (Sarang et al., 2008).
Third, if determining what constitutes adequate coverage is an open question, there is an increasing number of practical methods for measuring it. The commentary by Gray and Hoffman (2008) and the reports by Baldwin et al. (2008), Heimer (2008) and Donoghoe et al. (2008) each offer systems for monitoring harm reduction coverage that individually or combined can offer much needed information on when sufficient coverage among IDUs is obtained to prevent ongoing HIV transmissions among populations of drug injectors. These coverage measures add to the growing list of such measures (Bluthenthal, Ridgeway, et al., 2007; Vickerman et al., 2006) and represent a widening variation in project level indictors for coverage and national indicators. This wide variation is due largely to the absence of scientific consensus and donor and UN organization needs for reporting and evaluation, but also due to important differences in the epidemiology of IDU-related HIV in diverse country settings. A major practical challenge that governments will grapple with is how to harmonise and collect data for various coverage indicators at the national level while managing the data collection burden.
Fourth, more research is needed on quality measures of coverage. Reddy et al. (2008) show that coverage estimates based solely on the number of IDUs in touch with specific services can mask important factors that may contribute to effective interventions: the authors note that the quality and approach of interventions is variable and has not been studied yet in any detail in Bangladesh. Sarang et al. (2008) note that their data highlights a number of indicators that seem to have value from the client's perspective, and are therefore likely to be useful quality indicators. These include: “ease of geographic access and opening times; quality of the prevention materials offered; access to supportive and non-judgemental service provision; and openness to needs-led service provision rather than an emphasis on restrictive rules and regulations of exchange”. These findings are similar to those of the UNAIDS Best Practice document on High Coverage Sites: HIV Prevention among Injecting Drug Users in Transitional and Developing Countries (2006) and the WHO Guide to Starting and Managing Needle-Syringe Programmes (2008).
Fifth, achieving adequate harm reduction coverage is a political decision. Tempalski et al. (2008), build on increasing literature that documents the strong association between availability of harm reduction services and policy. In their considerations of 36 US metropolitan areas they suggest that grassroots activism is vital to starting NSPs, but that funding by state entities (federal, state or local governments) appears to lead to greater coverage. In addition, duration of programming is important: the longer a NSP operates, the more likely it is to reach the many hidden injectors and increase coverage.
One key area of further research is the environment in which harm reduction programmes operate and which may affect the programmes’ ability to scale up to high coverage. Sarang et al. (2008) remind us that “access to, and use of, injecting equipment is both socially situated and relative, depending upon an interplay of micro and macro environmental factors, such as: the relative accessibility and distribution of pharmacy-based and dedicated syringe distribution outlets; their programme characteristics; their staff-client interactions; the perceived quality and acceptability of service provision and syringe distribution policies; policing and law enforcement practices; and importantly, community norms relating to risk practices” and that, in reviews assessing syringe distribution and exchange, “there has been a tendency to neglect how situational factors shape the accessibility and acceptability of provision”. It is hoped that future research may address this gap in our understanding.
HIV is a global problem. The contribution of illicit drug injection to HIV is growing and will not reverse itself without sustained efforts in the areas of programme development, coverage, science and political change. It is our hope and belief that the reports and commentaries in this Supplementary Issue represent an important step forward in this effort.
Conflict of Interest
The authors have no conflict of interest to report.
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PII: S0955-3959(07)00271-X
doi:10.1016/j.drugpo.2007.12.008
© 2007 Elsevier B.V. All rights reserved.
