In our blog for March, Dave Burrows talks of ongoing concerns about HIV among people who inject drugs and who face a variety of human rights abuses.
The UNAIDS GAP Report from 2014 is quite stark on the issue of HIV among people who inject drugs (PWID): “It is estimated that worldwide there are nearly 12.7 million people who inject drugs. Approximately 1.7 million, or 13%, are also living with HIV. Injecting drug use is found in nearly every country. Typically, when heroin injection reaches a new community, there is an exponential increase in HIV transmission. People who inject drugs continue to face punitive legal environments, a variety of human rights abuses and have poor access to services; these and other factors combine to exacerbate their risks of acquiring HIV.”
The situation of PWID in Asia is particularly problematic. Most Asian epidemics are either wholly or in part driven by epidemics among PWID and their sexual partners. This situation has been well researched for more than two decades. Yet still, in virtually every country in Asia, many drug users cannot get access to the services they need to prevent HIV or to get treated when they are HIV-positive.
Harm Reduction International has found that, of 25 countries and states in Asia surveyed, eight states had no access to needle-syringe programs and ten had no access to opioid substitution therapy. These interventions are regarded as absolutely essential in the Comprehensive Package of Services for PWID promoted by UNAIDS, UNODC, WHO and PEPFAR. While the same study has found significant reductions in national HIV prevalence (for example from 70% HIV positive in Myanmar in the late 1980s to around 22% today), it is evident that substantial barriers continue to exist to PWID protecting themselves and others from HIV infection and getting help if they are HIV-positive.
THE WAY FORWARD
At APMGlobal Health (APMG; a social enterprise that works to improve the reach, quality and impact of HIV and health programmes among marginalised populations), we are using Testing and Treatment Cascades to bring home to politicians and policymakers the need for rapid and comprehensive scale-up of services to PWID. The process begins with a mapping and population size estimation process (preferably national) so that clear data are available about the number of individual PWID we are trying to reach. Then, using the existing data (available in most countries), we look at the percentage of PWID provided with the Comprehensive Package of Services, and specifically the percentage who receive a HIV test and know the result each six months. Where possible, we also look at the percentage of those found to be HIV-positive who are engaged with HIV care and antiretroviral therapy (ART). Ultimately, we seek to know what percentage of HIV-positive PWID have achieved viral load suppression (VLS).
By marrying two standard approaches – Cascades and Comprehensive Packages – this process encourages countries to meet the UNAIDS and WHO targets of trying to reach and test at least 90% of key populations; ensure that at least 90% of those who are HIV-positive are enrolled and maintained in HIV treatment; and achieve VLS in at least 90% of those PWID on ART. Instead of using different indicators to measure work with PWID in each country, this combined approach allows for comparison between and across countries and provides important data for decision-making on where to allocate resources for greatest benefit.
But achieving these 90% targets will not be easy. To get to the rosy scenario described above takes many major steps, including the tasks and challenges outlined below:
|Knowing who are actively involved in risk behaviours, how many individuals are PWID & where they are||Agreed definitions (on who exactly is part of the population)Robust population size estimationsChanges over time|
|Reaching a high percentage (at least 95%) of PWID, not only with education about HIV and prevention materials but with specific education about the usefulness of HIV testing||Potential human rights violations of PWIDLack of resources/ will to cover 90% of PWID with outreach education & easy access to testingLack of standardized unique identifier codeLack of agencies (usually NGOs) able/ willing to scale up to reach high % of PWID|
|Building trust with a high percentage (at least 90%) of PWID, so that each individual will undergo voluntary HIV testing||Requires change of focus from delivery of prevention materials/ information to real engagement with clients (at very high volumes)Lack of capacity within agencies (usually NGOs) able/ willing to scale up to reach high % of PWID|
|Linking outreach education and trust-building to actual HIV counselling and testing||May require rapid testing by NGO staff to ensure clients face no stigma in health systemAlternatively (or as well), may require building skills of HIV testing staff in government facilities to provide appropriate counselling and testing|
|Providing test results to a high percentage (near 100%) of PWID, with counselling to assist in maintaining negative status, and assistance to treatment for HIV+||Appropriate testing regimens (with resolved procurement & supply chain issues)Lack of capacity of most NGO and government health staff to provide high-quality post-test counsellingLack of linkages from testing to care|
|Of those who test positive, a high percentage (near 100%) need to be linked to HIV treatment, care and support services||Discrimination against PWID in provision of health servicesLack of access (affordable, geographically accessible) to ART for such a high percentage of PLHIV|
|Of those who require ART, near 100% need to be offered ART and need to continue on treatment||Discrimination against PWID in provision of ARTPWID are unlikely to stay on ART without assistance such as opioid substitution treatment which should be co-located with ART delivery|
After decades of research, we have a clear picture of what needs to be done to end the HIV epidemic among PWID in Asia. The approach outlined here will help countries meet all their United Nations General Assembly Special Session targets and ensure that drug users access the services they need in relation to HIV. If this approach is used across the key populations, it should stop HIV in every concentrated epidemic in the world. But sufficient resources will need to be provided to achieve this task.