HIV in people who use drugs: Need to focus on conditions of health delivery that create treatment interruptions

Among low-income and middle-income countries, almost half of all injecting drug users with HIV are in just five of these countries: China, Vietnam, Russia, Ukraine, and Malaysia. Access to antiretroviral treatment (ART) is disproportionately low in these countries -- IDUs make up two thirds of cumulative HIV cases in these countries, but only 25% of patients receiving ART. This third paper is by Daniel Wolfe, Open Society Institute, International Harm Reduction Development Program, New York, M. Patrizia Carrieri, of INSERM, France, and Donald Shepard, a health economist at Brandeis University's Heller School for Social Policy and Management.

Injecting drug users (IDUs) have successfully started ART in at least 50 countries, with evidence showing clearly that these patients can achieve excellent virological outcomes and with no greater development of drug resistance than other patients. Early adherence to ART is associated with long-term virological response, with behavioural support and provision of opioid substitution treatment (OST) increasing treatment success of ART in IDUs. Preliminary evidence suggests that increased ART provision to IDUs also reduces infectivity and HIV transmission, independent of needle sharing.

Not only is ART vital for saving lives and preventing transmission, but the evidence shows it is cost-effective. Data show clear benefits of targeting of ART to IDUs in areas with concentrated HIV epidemics (such as these five countries). Furthermore, the cost of drug dependence treatment is as little as one seventh that of addressing social and medical costs of untreated drug use.

"Our analysis focused on two treatments: provision of anti-viral therapy (ART) for and provision of methadone or buphenorphine for HIV-infected drug users. We found that both are highly cost-effective. Unfortunately, many barriers limit their use," said Shepard.

Systemic barriers to ART and OST provision include stigmatisation of IDUs in health settings, medical treatment separated by specialties, bans on treatment of active IDUs, hidden or collateral fees, and multiple requirements for initiation or modification of treatment for IDUs. In the five countries considered, fewer than 2% of IDUs have access to opiate substitution treatment.

Structural barriers to treatment provision result from wholesale criminalization of drug users. Barriers include sharing the names of IDUs seeking treatment with police, arrest and harassment of IDUs in or around clinical settings, and harassment of physicians who prescribe opioids. Even in Asian countries praised for initiation of OST programs, far greater numbers of IDUs are detained for years in "treatment and rehabilitation" settings that offer no medical evaluation, right of appeal, or evidence-based treatment or rehabilitation. ART and OST in these detention centres are largely unavailable. Incarceration of drug users, and interruption of ART and OST in prison, is also commonplace.

"Compared to detention policies in many countries, these treatments not only save lives, they also save money," said Shepard.

A necessary measure to improve ART coverage for IDUs is improved data collection, including an "equity ratio" to assess whether IDUs are receiving a fair share of antiretroviral treatment. The authors highlight that the Global Fund to Fight AIDS, Tuberculosis and Malaria, which between 2001 and 2008 has awarded about $180 million for HIV prevention in IDUs, does not ask grantees to detail IDU-related spending, even in countries where most of the HIV-infected population are IDUs. The U.S. President's Emergency Plan for AIDS Relief (PEPFAR), despite legal requirements to collect data about how many IDUs are reached through its programs, also fails to do so.

Other required improvements are integration of ART with OST and treatment for co-infections such as tuberculosis, and greater use of community-based treatment models and peer support.

In view of persistent human-rights violations and negative health effects of policing, detention, and incarceration, law and policy reform is needed to improve ART coverage of IDUs. The authors say that systemic improvements "are unlikely to succeed without action to resolve the fundamental structural tension between public health approaches that treat IDUs as patients and law enforcement approaches that seek to arrest them. Police registries, arbitrary detention, and imprisonment of people who have committed no crime apart from the possession of drugs for personal use are barriers to treatment and care that cannot be overcome by counselling, electronic reminders, or peer support."

They conclude: "A basic challenge remains in the reversal of social forces, including popular opinion, that portray IDUs as already dead or less than human, and so deserving of less-than-human rights. Resurrection of IDUs from this status is beyond the healing power of ART alone, although reformation of HIV treatment systems can help to emphasise that IDUs, including those actively injecting, are capable of making positive choices to protect their health and that of their communities," adding that referral to the 1948 Universal Declaration of Human Rights could guide an approach to improve treatment for IDUs and others vulnerable to HIV infection.