Rescuing people with HIV who use drugs
Injecting drug use is the most hidden dimension of the global HIV epidemic. Yet drug use is expanding across the world. As many as 16 million people inject drugs in at least 148 countries.1 Around 3 million (but perhaps as many as 6·6 million) people inject drugs and are HIV positive. Outside sub-Saharan Africa, about a third of HIV-related disease can be attributed to injecting drug use. Even within Africa, drug use is becoming an increasingly important driver of the epidemic.
Most countries have used the criminal justice system, not the health system, to address the problems of people who use drugs. But these legal approaches have failed. Criminalisation has reduced access to health care for people at risk of drug use.
Legal approaches do nothing to tackle the root causes or risk environments of drug use (it might actually make them worse). Put simply, locking people up does not work.
As the Series of papers we publish today shows,2—8 governments should reject law enforcement and embrace health solutions—specifically, policies of harm reduction (see panel for a definition, together with other definitions of commonly used terms in this Series). Each nation’s epidemic of HIV-related disease is different, calling for unique tailored approaches to control and defeat.
But at the centre of any response to the virus in people who use drugs is combination prevention—a mix of safe-injection programmes and packages of care (eg, opioid substitution therapy and antiretroviral therapy) aimed at alleviating the risk environment faced by drug users. These initiatives could avert as many as two-thirds of HIV infections that are associated with drug use. The case for universal access to these prevention programmes is scientifically sound and morally urgent.
Panel
Glossary—HIV in people who use drugs
Amphetamine-group substances
A mixed class of agents, also called amphetamine-type substances, which include methamphetamine, other amphetamines, and an array of related synthetic compounds derived from ephedra family of plants or synthetic precursors. They can be ingested, smoked, or injected in various formulations.
Buprenorphine
A partial opioid agonist used in substitution therapy for opioid dependence. A combination agent, suboxone, combines buprenorphine and naloxone in single formulation and is being investigated as an intervention to prevent HIV infection in people who inject drugs.
Cocaine
Stimulant derived from leaves of the coca plant, Erythroxylum coca, which is refined into cocaine powder and a waxy form known as crack cocaine. Cocaine can be inhaled, ingested, smoked, or injected.
Decriminalisation
Legal approaches which seek to reduce criminal penalties, including incarceration, associated with being a drug user and with possession of illicit agents for personal use.
Drug use/abuse
Use of psychoactive agents is common globally and might or might not lead to health risks. Abuse is generally defined as heavy or problematic use, and is associated with dependence, tolerance, and addiction. There is great heterogeneity in use of these terms.
Harm reduction
Policies, programmes, and practices that aim to reduce harms associated with use of psychoactive drugs in people unable or unwilling to stop. Defining features are focus on prevention of harm and on people who continue to use drugs. Core components include NSP, evidence-based drug treatment, including OST, enabling policy environment, and access to antiretroviral therapy for HIV-positive people who use drugs.
IDU
Injecting (formerly, intravenous) drug user. A person who injects drugs, most commonly heroin and cocaine, but also stimulants (amphetamines). IDUs have been among the most affected groups for blood-borne pathogens including HIV and hepatitis B and C viruses.
MAT
Medication-assisted therapy. Treatment approach that uses opioid substitution therapy (OST) with methadone, buprenorphine, or other agonists or antagonists to support antiretroviral therapy for opioid-dependent patients with HIV infection.
Methadone
Opioid agonist in liquid form which has long been used for OST. Methadone-maintenance therapy (MMT) is a widely used approach to treat heroin and other opioid dependency.
NSP
Needle and syringe programmes. A core component of harm reduction. NSPs provide sterile injection equipment, and get used equipment out of use and safely disposed. An entry point into treatment and care for many heavy users.
Opioids
Large class of agents, licit and illicit, derived from active compounds of the opium poppy, Papaver somniferum. Opium paste or base is the raw plant extract, generally smoked. Morphine is major active component. The diacetylated form of morphine is heroin. Opioids in common medical use include morphine, codeine, demerol, dilaudid, and oxycontin. Potent analgesics that mimic agonists (endorphins) at endogenous receptors in mammalian brain, they all have capacity to induce dependence.
Risk environment
The structural, social, political, and environmental contexts and influences that can drive or reduce risk practices and vulnerabilities.
HIV is not only a public health predicament. It is also a human rights challenge. In addition to access to integrated care, issues of stigma and discrimination must be addressed. No longer should drug users have to face denial of access to treatment services or information. No longer should they have to accept poor coverage of services.8 No longer should they face criminalisation or disproportionate legal penalties. No longer should they have to face abuse perpetrated under the guise of research (only last year, reports revealed the forced participation of drug users in a trial of a herbal cure for their drug dependence9).
The solution to these pervasive failures begins with political will—not only among national governments but also among international agencies, including WHO. Civil society is important here too. But so is the medical community, which continues to miss opportunities for shaping and changing public and political opinions about injecting drug use and HIV infection. The health-science community has a crucial part to play, not least in strengthening reliable knowledge about harm reduction and drug policy making.
We want this Series to be an inflexion point in the history of injecting drug use and HIV infection. We want to see the latest scientific evidence trigger a more humane response to this, one of the most preventable sources of HIV disease. And we want to see inappropriately aggressive, state-sponsored hostility to drug users replaced by enlightened, scientifically driven attitudes and more equitable societal responses. We recognise that the barriers to these hopes are many and deeply rooted across continents and cultures. But we also know that science can catalyse unprecedented social change, and unprecedented social change is what is needed for the millions of marginalised people infected with HIV who use drugs.
We are extremely grateful to an extraordinary group of scientists who made this Series possible, but especially to Chris Beyrer who was the inspiration behind the project. His contribution was ably supported by Steffanie Strathdee, Adeeba Kamarulzaman, and Kasia Malinowska-Sempruch. We thank the Open Society Institute for its generous financial support.
###
References
1 Mathers BM, Degenhardt L, Phillips B, et alfor the 2007 Reference Group to the UN on HIV and Injecting Drug Use. Global epidemiology of injecting drug use and HIV among people who inject drugs. Lancet 2008; 371: 1733-1745.
2 Strathdee SA, Hallett TB, Bobrova N, et al. HIV and risk environment for injecting drug users: the past, present, and future. Lancet 201010.1016/S0140-6736(10)60743-X. published online July 20.
3 Degenhardt L, Mathers B, Vickerman P, Rhodes T, Latkin C, Hickman M. Prevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed. Lancet 201010.1016/S0140-6736(10)60742-8. published online July 20.
4 Wolfe D, Carrieri MP, Shepard D. Treatment and care for injecting drug users with HIV infection: a review of barriers and ways forward. Lancet 201010.1016/S0140-6736(10)60832-X. published online July 20.
5 Altice FL, Kamarulzaman A, Soriano VV, Schechter M, Friedland GH. Treatment of medical, psychiatric, and substance-use comorbidities in people infected with HIV who use drugs. Lancet 201010.1016/S0140-6736(10)60829-X. published online July 20.
6 Colfax G, Santos G-M, Chu P, et al. Amphetamine-group substances and HIV. Lancet 201010.1016/S0140-6736(10)60753-2. published online July 20.
7 Ju"rgens R, Csete J, Amon JJ, Baral S, Beyrer C. People who use drugs, HIV, and human rights. Lancet 201010.1016/S0140-6736(10)60830-6. published online July 20.
8 Beyrer C, Malinowska-Sempruch K, Kamarulzaman A, Kazatchkine M, Sidibe M, Strathdee SA. Time to act: a call for comprehensive responses to HIV in people who use drugs. Lancet 201010.1016/S0140-6736(10)60928-2. published online July 20.
9 Human Rights Watch. Cambodia: stop forced participation in drug trials. http://www.hrw.org/en/news/2009/12/19/cambodia-stop-forced-participation-drug-trials. (accessed June 22, 2010).
###
Richard Horton, Pam Das
The Lancet, Volume 376, Issue 9737, Pages 207 - 208, 24 July 2010
doi:10.1016/S0140-6736(10)61025-2