Review
What has been achieved in HIV prevention, treatment and care for people who inject drugs, 2010–2012? A review of the six highest burden countries

https://doi.org/10.1016/j.drugpo.2013.08.004Get rights and content

Abstract

Objective

In 2010 the international HIV/AIDS community called on countries to take action to prevent HIV transmission among people who inject drugs (PWID). To set a baseline we proposed an “accountability matrix”, focusing upon six countries accounting for half of the global population of PWID: China, Malaysia, Russia, Ukraine, Vietnam and the USA. Two years on, we review progress.

Design

We searched peer-reviewed literature, conducted online searches, and contacted experts for ‘grey’ literature. We limited searches to documents published since December 2009 and used decision rules endorsed in earlier reviews.

Results

Policy shifts are increasing coverage of key interventions for PWID in China, Malaysia, Vietnam and Ukraine. Increases in PWID receiving antiretroviral treatment (ART) and opioid substitution treatment (OST) in both Vietnam and China, and a shift in Malaysia from a punitive law enforcement approach to evidence-based treatment are promising developments. The USA and Russia have had no advances on PWID access to needle and syringe programmes (NSP), OST or ART. There have also been policy setbacks in these countries, with Russia reaffirming its stance against OST and closing down access to information on methadone, and the USA reinstituting its Congressional ban on Federal funding for NSPs.

Conclusions

Prevention of HIV infection and access to HIV treatment for PWID is possible. Whether countries with concentrated epidemics among PWID will meet goals of achieving universal access and eliminating new HIV infections remains unknown. As long as law enforcement responses counter public health responses, health-seeking behaviour and health service delivery will be limited.

Introduction

In The Lancet's 2010 issue ‘HIV in people who use drugs’, there was a call for urgent action to prevent HIV transmission among people who inject drugs (PWID), and to ensure essential treatment and care be provided for drug dependence and HIV (Beyrer et al., 2010). To set a baseline for assessing progress, we proposed an “accountability matrix” to measure the response to HIV among PWID (Beyrer et al., 2010) in six countries that account for half of the global population of PWID (B. Mathers et al., 2008): China, Malaysia, Russia, Ukraine, Vietnam and the USA. It used core indicators, compiled through systematic reviews (B. Mathers et al., 2008; B. M. Mathers et al., 2010), of the epidemiology of injecting drug use (IDU) and of HIV among PWID, and coverage of PWID with three interventions with evidence of effectiveness (Degenhardt et al., 2010, MacArthur et al., 2012; B. M. Mathers et al., 2010, Ni et al., 2012, Wolfe et al., 2010) and cost-effectiveness (Ni et al., 2012, Yen et al., 2012) in preventing and treating HIV: opioid substitution therapy (OST), antiretroviral therapy (ART) and needle and syringe programmes (NSP). We also called for an end to forced labour camps and other forms of detention as a response to drug use which have no evidence of efficacy in reducing HIV risks (Beyrer et al., 2010, Jürgens et al., 2010, Wolfe et al., 2010).

Recent commitments aiming for “zero new HIV infections among people who use drugs” (UNAIDS, 2011, http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2010/JC2034_UNAIDS_Strategy_en.pdf, accessed on February 15th 2012) and “an AIDS-free generation” (Obama, 2011) demand that progress accelerates. There have been strong calls from international and supranational bodies urging action in this sphere, including the Global Commission on drug policy and the Commission on HIV and the law. But will that happen? In light of the recently held XIX International AIDS Conference in Washington, DC, we consider progress of these six countries. In this paper we update the accountability matrix for the six countries.

Section snippets

Method

To update epidemiological data and indicators estimating intervention coverage, we followed the search strategy used in the 2010 review of epidemiology coverage indicators undertaken by Mathers et al. (B. Mathers et al., 2008; B. M. Mathers et al., 2010). We searched for peer-reviewed and grey literature published since December 2009. Data were selected, and estimates calculated, as per decision rules used in previous reviews. This process is summarised in Panel 1 below (see also web appendix

Results

The systematic search is summarised in Fig. 1.

Discussion

This review updated data on the epidemiology of IDU and HIV, and estimates coverage of injecting populations with core HIV prevention and care services. There have been successes in the past two years. Policy shifts and increases in access to HIV prevention and treatment are increasing coverage of key interventions for PWID in Asia and Ukraine. Increases in the share of PWID receiving ART in Vietnam, and rapidly increasing numbers on OST in China and Vietnam, offer lessons for other countries

Limitations

This review was subject to limitations similar those that existed for our earlier reviews (B. Mathers et al., 2008; B. M. Mathers et al., 2010). Our search of the peer-reviewed literature was comprehensive, but many of the data we sought are not necessarily available in peer-reviewed publications; this is particularly the case for information describing the situation in low and middle income countries. Other limitations include our inability to search in multiple languages, the inaccessibility

Conclusions

Stopping HIV infections among PWID, and achieving access to ART have largely been achieved in countries such as Australia and Switzerland. Whether countries with concentrated epidemics among PWID will follow through on pledges to achieve universal access or “get to zero” HIV infections remains an open question.

International and national financial commitments must be made and kept. In an era of constrained resources, financial arguments for maximising return on investment, by ensuring funds are

Role of the funding source

Funding was provided by the Center for Public Health and Human Rights, Johns Hopkins School of Public Health; authors CB and AW are staff members of this faculty. Funding was also provided by Global Drug Policy Program, Open Society Foundations; author KMS is Director of this programme.

Acknowledgements

We wish to acknowledge the Johns Hopkins School of Public Health graduate students who assisted us with the updates of the systematic reviews, namely: Tricia Aung, Erica Layer, Hieu Pham, Ju Nyeong Park, Benjamin A. Williams, and Kelsey Wright. The Center for Public Health and Human Rights, Johns Hopkins School of Public Health, and the Global Drug Policy Program, Open Society Foundation. Louisa Degenhardt is supported by an Australian National Health and Medical Research Council (NHMRC)

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