Landmark study on HIV prevention for injecting drug users appears in The Lancet
The provision of HIV prevention services for injecting drug users, essential to contain the spread of HIV, is inadequate in most countries around the world and presents a critical public health problem according to a landmark review by Australian researchers published in this week’s edition of The Lancet.
“Injecting drug use is an increasingly important cause of HIV transmission in most countries,” says the study’s lead author Dr Bradley Mathers from the National Drug and Alcohol Research Centre (NDARC) at the University of New South Wales. “Of the estimated 16 million injecting drug users worldwide three million are thought to be HIV positive. Injecting drug users are estimated to account for 10 per cent of all those living with HIV around the globe.”
Dr Mathers and his colleagues found that while Australia rated as one of the best countries in the world for provision of HIV prevention services among injecting drug users, there were huge discrepancies in coverage worldwide including some countries having no HIV prevention services for injectors.
The current study is the first in the world to systematically assess the provision of interventions known to prevent the spread of HIV among injecting drug users, including: programs to provide clean needles and syringes, drug dependence treatments such as opioid substitution therapy (OST), antiretroviral therapy (ART) for HIV and condom provision.
Australia has the second highest rate of clean needle provision for injecting drug users in the world – 213 clean needles per injecting drug user every year – but globally, only eight per cent of injectors have accessed needle and syringe programs in the last year. This ranged from an estimated 100 per cent in the Czech Republic and Ireland to less than three per cent in China, Malaysia and Thailand.
Opioid substitution therapy (such as methadone) is available in 70 of the 151 countries with a known injecting drug user population. A notable exception is Russia which contains the world’s second largest injecting population after China but has no opioid substitution therapy. In contrast Australia has had long established and wide spread availability of opioid substitution therapy for people who are heroin dependent – proven to reduce the spread of HIV.
“Our high level of prevention in Australia has paid off with low levels of HIV infection among injecting drug users compared with countries with a similar level of injecting drug use,” said Dr Mathers. “For example a review of prevalence of HIV among injecting drug users conducted in 2008 found that only 1.5 per cent of our injecting drug user population were HIV positive, compared with countries such as Russia and the Ukraine where close to 40 per cent of injectors are HIV positive.”
The median number of injecting drug users receiving HIV treatment tended to be lower in developing countries. Globally only 1 in 25 HIV positive injecting drug users receives treatment for HIV. The number of HIV positive injectors receiving antiretroviral therapy varied from less than one per cent in Chile, Kenya, Pakistan and Russia to full coverage in some European countries.
The authors say that HIV prevention treatment and care services for injecting drug users are proven to be clinically effective, but to exert a population level effect they need to be delivered to scale. “Our findings suggest that, worldwide, there are few countries in which the level of intervention coverage is sufficient to prevent HIV transmission.”
They conclude: “Governments that have not made needle and syringe programs and opioid substitution available need to be convinced that these interventions are the most effective ways to stop HIV spreading among injecting drug users, and to the wider community.”
Mathers, Degenhardt et al: HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional and national coverage. The Lancet, March 1 2010 (online). http://www.thelancet.com