The provision of HIV prevention services for injecting drug users, which is essential to contain the spread of HIV, is inadequate in most countries around the world and presents a critical public health problem, according to an Article published Online First in The Lancet.
Injecting drug use is an increasingly important cause of HIV transmission in most countries around the world. Of the estimated 16 million injecting drug users worldwide, 3 million are thought to be HIV positive. Injecting drug users are estimated to account for 10% of all those living with HIV around the globe.
Bradley Mathers, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia, and colleagues undertook a systematic review to assess the provision of interventions know to be effective in preventing the spread of HIV among injecting drug users, including: programs to provide clean needles and syringes, drug dependence treatments such as opioid substitution therapy, antiretroviral therapy for HIV, and condom provision.
They found that, globally, coverage of these services is very poor, but coverage varies greatly between countries. Worldwide only 8% of injectors have accessed needle and syringe programs in the last year; at the country level this ranged from an estimated 100% in the Czech Republic and Ireland to less than 3% in China, Malaysia, and Thailand. Opioid substitution therapy (involving drugs such as methadone) is available in 70 countries, a notable exception being Russia which contains the world's second largest injecting population after China. The median number of drug users receiving HIV treatment tended to be lower in developing countries; globally only 1 in 25 HIV positive injecting drug users receives antiretroviral treatment for HIV.
The authors say: "although the number of countries with core HIV prevention services is growing, the level of coverage in injecting drug users is poor in many countries." They add: "HIV prevention treatment and care services for injecting drug users are 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."
In an accompanying Comment, Dr Don C Des Jarlais, Beth Israel Medical Center, New York City, NY, USA, and colleagues say that the inadequate coverage of HIV services for injecting drug users (IDUs) means that policy makers must bring their policies and programmes in line with scientific evidence.
"Over the past 25 years, several useful theories have been developed for changing the health behaviour of IDUs and others at high risk for HIV. It may be time to apply those theories to changing the behaviour of policy makers. Many policy makers frame HIV prevention for IDUs in terms of what appears to encourage or condone drug use, and then oppose harm-reduction programmes. It might be more effective to frame HIV prevention for IDUs in terms of the health of the community as a whole, and that public health is fundamental to the economic wellbeing of a society."
They conclude: "Long-term sustained efforts to protect the health of individuals who use both licit and illicit drugs might require that policy makers acquire a basic scientific understanding of drug use and addiction, and frame policies toward drug users within a public health and human rights perspective."
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