Preventing HIV Infection Among Injecting Drug Users in High-Risk Countries An Assessment of the Evidence (2007) / Chapter Skim
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, may be at increased risk of HIV infection because of high-risk sexual behaviors. There are an estimated 13.2 million injecting drug users worldwide-78 percent of whom live in developing or transitional countries (Aceijas et al., 2004)
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and the Bill & Melinda Gates Foundation commissioned the Institute of Medicine to undertake an expedited review of the scientific evidence on strategies to prevent HIV transmission through contaminated injecting equipment, with a specific focus on highrisk2 countries -- namely in Eastern Europe, the Commonwealth of Independent States, and significant parts of Asia -- where injecting drug use is, or is on the verge of becoming, the primary driver of the HIV epidemic. The charge to the Committee included five questions.
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The term "harm reduction" is often used to describe programs such as sterile needle and syringe access, because their primary aim is to reduce the harms related to drug use among those who are unable or unwilling to stop using drugs. However, because the term has a wide range of interpretations, the Committee refers to all interventions in this report as HIV prevention programs for IDUs.
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In maintenance therapy, the agonist agent is administered at higher doses for a sustained period. The goal of maintenance treatment is to reduce illicit drug use and high-risk behavior by building cross-tolerance to the effects of other opioids, thereby allowing patients to stabilize physiologically and psychologically, so they can reengage in normal life activities (IOM, 1990; WHO et al., 2004)
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The Committee uses the term "multi-component HIV prevention programs that include needle and syringe exchange" to refer to programs that combine NSE with one or more of the following services: outreach, health education in risk reduction, condom distribution, bleach distribution coupled with education on needle disinfection, and referrals to substance abuse treatment and other health and social services. Outreach and education Outreach and education rely on peers and local health workers to identify IDUs and provide education on preventing HIV infection, and to serve as guides to health and social services (WHO, 2004a)
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The Committee interpreted this question as asking about the extent to which these interventions affect drug-related HIV risk behavior, including frequency of drug use, injection, and sharing of contaminated equipment. Drug Treatment Pharmacotherapies: Strong and consistent evidence from a number of welldesigned, randomized controlled trials shows that opioid agonist maintenance treatment -- including methadone and buprenorphine -- is effective in reducing illicit opioid use and increasing retention of opioid-dependent patients in drug abuse treatment (Mattick et al., 2003a,b; Gowing et al., 2004, 2005)
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More research is also needed to determine the relative effectiveness of various psychosocial interventions in treating opioid dependence in places where opioid agonist maintenance therapy is not available or accessible. Because proven pharmacological interventions are available only for opioid addiction and not for stimulants or other classes of injectable drugs, psychosocial approaches are the primary treatment option for individuals dependent on these substances.
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Sterile Needle and Syringe Access Multi-component programs that include needle and syringe exchange: A large number of studies and review papers -- most from developed countries -- show that participation in multi-component HIV prevention programs that include NSE is associated with a reduction in drug-related HIV risk behavior, including self-reported sharing of needles and syringes, unsafe injection and disposal practices, and frequency of injection.
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Given consistent evidence that multi-component HIV prevention programs that include sterile needle and syringe is associated with reductions in drug-related HIV risk behavior, such programs should be implemented where feasible. Alternative access to needles and syringes: Eliminating criminal penalties for possessing needles and syringes -- and enhancing legal access via pharmacy sales, voucher schemes, and physician prescription programs -- are alternative avenues for making sterile needles and syringes available to IDUs.
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Sterile Needle and Syringe Access Programs Few studies have evaluated the effect of NSEs on sex-related HIV risk behavior. In two early prospective cohort studies, participants in needle and syringe exchange reported decreases in sex-related risk behavior (Donoghoe, 1989; Hart, 1989)
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. Question 3: How effective are drug treatment programs, sterile needle and syringe access programs, and outreach in reducing HIV transmission among IDUs?
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Sterile Needle and Syringe Access Programs Multi-component programs that include needle and syringe exchange: The Committee found that virtually all evaluated programs combined NSE with other prevention strategies, such as outreach, risk reduction education, condom distribution, bleach distribution and education on needle disinfection, and referrals to substance abuse treatment and other health and social services. Evaluation studies of such multi-component HIV prevention programs have primarily examined their impact on HIV risk behavior rather than HIV incidence.
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Such a trial could specifically assess the impact of needle and syringe exchange and outreach components on the primary outcome measure -- incidence of HIV infection (and, as feasible, hepatitis C infection) -- as well as important secondary outcome measures (see Appendix E for further details)
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For instance, the World Health Organization (WHO) recommends a comprehensive HIV prevention program for IDUs that includes outreach, information, education, and communication, risk reduction counseling, HIV testing and counseling, disinfection programs, sterile needle and syringe access programs, disposal of used injecting equipment, drug treatment services, agonist pharmacotherapy programs, HIV/AIDS treatment and care, primary health care, and peer education (WHO, 2005b)
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. Some recent studies -- mostly mathematical models of the costs of HIV transmission among injecting drug users -- also suggest that programs that include needle and syringe exchange are cost-effective (e.g., Laufer, 2001; Cabases and Sanchez, 2003)
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Local communities may also object to programs that include needle and syringe exchange and opioid agonist maintenance treatment because they fear that these programs will attract drug users who may commit crimes and discard needles and other drug paraphernalia in their neighborhoods (NRC and IOM, 1995)
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In countries where injecting drug use is the primary source of HIV infection, national programs must address the challenges of both drug use and HIV. The Committee has reviewed the evidence regarding interventions for injecting drug use and HIV among IDUs, and hopes it has provided policymakers a knowledge base regarding what works.
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- The effectiveness of naltrexone for different patient populations and in different settings. - The relative effectiveness of various psychosocial interventions in treating opioid dependence in places where opioid agonist maintenance therapy is not available or accessible.
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- Integration of effective strategies for reducing sexual risk behavior and sexual transmission of HIV into multi-component programs that include sterile needle and syringe exchange and outreach and education. - The potential unintended consequences of HIV prevention programs that include needle and syringe exchange, such as increases in new drug users or in discarded needles in the community, and strategies to address such prob lems, if they are found.
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1997. High rates of HIV infection among injection drug users participating in needle exchange programs in Montreal: Results of a cohort study.
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1998. Effectiveness of psychosocial interventions in preventing HIV risk behaviour in injecting drug users.
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2001. Cost-effectiveness of syringe exchange as an HIV prevention strategy.
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2000. Adherence to HAART in French HIV-infected injecting drugs users: The contribu tion of buprenorphine drug maintenance treatment.
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2005. The social structural production of HIV risk among injecting drug users.
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1994. Methadone treatment as a determinant of HIV risk reduction among injecting drug users: A nested case-control study.
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2005a. Evidence for Action: Effectiveness of Drug Dependence Treatment in Prevent ing HIV Among Injecting Drug Users.
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