Prevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed

doi:10.1016/S0140-6736(10)60742-8

The Lancet

Volume 376, Issue 9737, 24–30 July 2010, Pages 285-301

https://doi.org/10.1016/S0140-6736(10)60742-8 Get rights and content

Summary

HIV can spread rapidly between people who inject drugs (through injections and sexual transmission), and potentially the virus can pass to the wider community (by sexual transmission). Here, we summarise evidence on the effectiveness of individual-level approaches to prevention of HIV infection; review global and regional coverage of opioid substitution treatment, needle and syringe programmes, and antiretroviral treatment; model the effect of increased coverage and a combination of these three approaches on HIV transmission and prevalence in injecting drug users; and discuss evidence for structural-level interventions. Each intervention alone will achieve modest reductions in HIV transmission, and prevention of HIV transmission necessitates high-coverage and combined approaches. Social and structural changes are potentially beneficial components in a combined-intervention strategy, especially when scale-up is difficult or reductions in HIV transmission and injection risk are difficult to achieve. Although further evidence is needed on how to optimise combinations of interventions in different settings and epidemics, we know enough now about which actions are effective: the challenge is to deliver these well and to scale.

Introduction

In most world regions, HIV infection is concentrated in subsets of the population exposed to particular HIV transmission risks, such as people who inject drugs.¹ Injecting drug use takes place in 151 countries,² with an estimated 11–21 million such users in 2007, of whom 0·8–6·6 million were estimated to be living with HIV.³

HIV transmission is a risk for all populations of injecting drug users (IDUs), with potential for the virus to spread rapidly between those who inject drugs (via injections and sexual risk) and, possibly, to the wider community through sexual transmission.⁴ The risk of infection after injection with an HIV-contaminated syringe is estimated to be 0·63–2·4% (median 0·8%; around 1 in 125 injections),⁵ with a potentially lower, albeit not quantified, transmission risk from sharing other contaminated drug-use equipment. The risk of HIV transmission between HIV-positive IDUs and their sexual partners is estimated at 0·02–0·05%6, 7, 8 per heterosexual sex act (ie, 1 in 2000–5000 sex acts); the estimated risk per act of receptive anal intercourse between men is 0·82% (0·24–2·76%).⁹

Key messages

•
Opioid substitution therapy (OST), needle and syringe programmes (NSPs), and antiretroviral therapy (ART) reduce risks of HIV infection in injecting drug users (IDUs)
•
Individual-based and network-based psychosocial interventions can reduce injecting and sexual risk; people who inject drugs can play an important part in development and delivery of such responses
•
Augmented research and programme attention needs to be directed towards psychostimulant injectors, since proven pharmacotherapies for substitution do not exist as they do for opioids
•
Model projections suggest high coverage of ART, OST, and NSPs in combination are important for reduction of incidence of HIV infection in IDUs by more than 50%; very high intensity and coverage of single interventions is necessary to achieve similar effects; short-term, small-scale, single interventions are unlikely to be effective
•
Current coverage of interventions for injecting drug use is inadequate; annually worldwide, perhaps 5% of drug injections are covered by a sterile needle and syringe provided by an NSP; eight clients receive OST for every 100 IDUs (range 6–12); and four IDUs receive ART for every 100 HIV-positive IDUs (range 2–18)
•
Structural interventions might be needed when scale-up is difficult or when intervention efforts do not reduce injecting risk and transmission of HIV infection; an innovative evaluative evidence base is needed to understand the effect of structural interventions
•
Surveillance of the epidemic and response is crucial, but typically poor; studies of transmission of HIV infection and effects of interventions should have funding priority and be nested in ongoing surveillance programmes; evaluation of interventions should include cost-effectiveness studies
•
Limitations in evidence need not limit response; sufficient justification exists on human rights and public-health grounds for scaling up now; evidence-based prevention of HIV infection should be a policy priority in all countries where injecting drug use takes place

Here, we review evidence on interventions that avert injection-related HIV transmission, by either prevention of injections with HIV-contaminated equipment or reduction of HIV transmission when needle-sharing does take place. Some interventions aim to decrease the total number of injections, either by treatment of drug dependence or through efforts to dissuade people from drug use, by punishment (typically, incarceration). Other strategies aim specifically to reduce unsafe injections: provision of clean equipment; education to encourage individuals to inject drugs in a safe way; and facilities where people can inject safely (supervised injecting centres). Other approaches aim to lower the risk of sexual transmission, by provision of condoms, through behavioural interventions to encourage safe sexual practices, and by treatment of sexually transmitted infections (STIs). By reducing viral load, antiretroviral treatment (ART) can diminish the likelihood of HIV transmission if exposure happens.

Our key outcome is prevention of HIV transmission in IDUs. First, we summarise evidence on the effectiveness of different individual-level approaches to prevention of HIV transmission. Second, we review coverage of three prevention interventions, regionally and globally. Third, we model the effect of increased coverage and combined interventions on HIV transmission and prevalence in IDUs. A range of countervailing contextual and cultural factors—so-called structural factors above the level of the individual, looked at in the first paper in this Series¹⁰—could affect both HIV risk and the capacity to deliver effective interventions.¹¹ We discuss structural-level interventions that could increase intervention scale-up and boost community-level effects of risk reduction in IDUs.

Section snippets

Interventions targeting people who inject drugs

Table 1 details evidence of the effect of different interventions on various outcomes of interest (a glossary describing these strategies is in the webappendix p 5). The grades (A–D) describe the highest level of evidence available for the domains. Several points are salient. First, the strength of evidence varies across interventions. Second, at present, approaches with the greatest potential effect seem to be needle and syringe programmes (NSPs), opioid substitution treatment (OST), and ART.

Combined interventions in prevention

In reviews of prevention, researchers have noted that combinations of interventions are more likely to have an effect than single interventions;20, 103, 104 this finding is not surprising since no one approach addresses all outcomes of importance (injections, injection risk, sexual risk, and HIV infectivity; table 1). Accordingly, data from cohort and modelling studies have shown that the effects of NSPs and OST on HIV incidence in IDUs are negligible if delivered as stand-alone strategies.55,

Current intervention coverage

Measurement of the scale of interventions is a challenge and is inconsistent across countries and international agencies,¹¹⁴ and quality of data describing the epidemic and the response varies substantially (panel 3). We know, however, that NSPs, OST, and ART are being implemented in an increasing number of countries,1, 2, 115, 116 though with very large differences in coverage.

In a systematic review,² researchers noted that NSPs had been introduced in 82 of 151 countries where injecting drug

Potential of social and structural interventions

Interventions operating at the population or community level are known as structural interventions.11, 103 As discussed in the first paper in this Series,¹⁰ social and structural factors can inhibit the capacity of IDUs to reduce their risk of HIV infection or diminish the extent to which prevention strategies are delivered and used.11, 118, 119 In circumstances when interventions have not been introduced or scale-up is inadequate, or when the effect of strategies on HIV transmission is limited

Improvement of HIV prevention for people who inject drugs

Prevention of HIV infection in IDUs is achievable. We know how HIV is transmitted, and we recognise a core set of strategies that can limit its spread. Model projections described here suggest not only that combination and increased coverage of interventions will prevent HIV transmission but also that high levels of coverage need to be sustained for long periods. The effect of these core strategies is greatest when background HIV prevalence is low. Therefore, delays to introduction and scale-up

Conclusions

Prevention of HIV infection needs high coverage and combined approaches. Single interventions, even at high coverage, are likely to achieve only modest reductions in HIV transmission, particularly in settings with very high levels of HIV risk behaviours. Governments, policy makers, and public-health officials must be engaged and convinced of the importance of scaling up. Further lines of evidence could assist in justification of rapid scale-up when resistance occurs, including evaluation of

Search strategy and selection criteria

We used several search strategies and focused wherever possible on identification of systematic reviews and meta-analyses. First, with respect to interventions to prevent HIV infection, we searched in: the Cochrane Library; the Centre for Reviews and Dissemination (University of York); Evidence-Based Medicine Reviews; the Campbell Collaboration Library of Systematic Reviews; DRUG; Global health; and Project Cork (tailored search terms for each database are described in detail in the

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Injecting in public places may increase the risk of drug and health-related harms among people who inject drugs (PWID). We examined the prevalence of public injecting and associations with non–fatal overdose, needle/syringe sharing, sexual health, and mental health among PWID in Iran.
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Of 2388 respondents, 69.6 % reported public injecting in the previous year. Self-identifying as men (adjusted odds ratio [aOR] = 4.21; 95 % confidence intervals [95 % CI]: 2.31, 7.65), homelessness (aOR = 6.81; 95 % CI: 5.10, 9.10), high injection frequency (aOR = 1.58; 95 % CI: 1.03, 2.44), and free needle/syringe uptake (aOR = 1.47; 95 % CI: 1.04, 2.07) were significantly associated with public injecting. Compared to PWID who primarily inject in non–public places, PWID who mostly used public places had significantly greater odds of reporting non–fatal overdose (aOR = 2.02; 95 % CI: 1.01, 4.02), needle/syringe sharing (aOR = 1.77; 95 % CI: 1.08, 2.90), unsafe sexual practices with casual sexual partners (aOR = 2.16; 95 % CI: 1.03, 4.55), suicidal ideation (aOR = 1.50; 95 % CI: 1.02, 2.21), and self-harm (aOR = 1.78; 95 % CI: 1.24, 2.54) in the last three months.
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The aim of this article is twofold: to present the sociodemographic profiles of people who inject drugs (PWID) in Togo and to assess the prevalence of health risks (sexually transmitted infections [STIs], the hepatitis C virus, and HIV), the problems linked to drug injection, and the factors characterizing PWIDs.
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In the sampling, the results revealed prevalence of 17% for STIs and 53% for the hepatitis C virus. The onset of medical problems and STI signs was significantly triggered when the person was female, over 25 years of age, polygamous, not attending school, unemployed, and had been using drugs for more than five years. Moreover, reused injection equipment was shown to be associated with the high STI prevalence.
Drug injection is dangerous and results in numerous health problems. This study shows that PWID vulnerability of stems from specific characteristics, such as being uneducated, single, unemployed, bereft of parents, and having a low monthly income. Additional research is required to further investigate the health risks associated with drug injection in view of providing PWIDs with comprehensive care.
L'objectif de cet article est double : décrire les profils sociodémographiques et évaluer la prévalence des risques sanitaires (IST, VHC, VIH) et de leurs facteurs associés, chez les personnes qui s'injectent des drogues (UDIs) au Togo.
À partir d'un questionnaire, l’étude descriptive et transversale a été réalisée auprès d'une population de 384 usagers de drogues injectables au Togo. Il a porté sur les caractéristiques sociodémographiques, l'historique des consommations et les problèmes et risques sanitaires connus. L'échantillonnage a permis la collecte de données dans toutes les régions du pays.
Les résultats ont montré une prévalence de 17 % pour les IST et de 53 % pour le VHC. L'apparition de problèmes médicaux et de signes d'IST est significativement élevée lorsque la personne est de sexe féminin, âgée de plus de 25 ans, polygame, non scolarisée, sans profession et avec plus de 5 ans de consommation de drogues. En outre, il a été démontré que la réutilisation du matériel d'injection est significativement associée aussi à l'apparition élevée d'IST.
L'injection de drogues comporte beaucoup de dangers et de problèmes de santé. Elle a montré que la vulnérabilité des UDIs provient de caractéristiques particulières (non éduqué, célibataire, chômeur, orphelin, avec un faible revenu mensuel). Des recherches supplémentaires sont nécessaires pour approfondir les risques sanitaires liés à l'injection de drogues et pour initier de véritables efforts de prise en charge globale des UDIs.

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SeriesPrevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed

Summary

Introduction

Section snippets

Interventions targeting people who inject drugs

Combined interventions in prevention

Current intervention coverage

Potential of social and structural interventions

Improvement of HIV prevention for people who inject drugs

Conclusions

Search strategy and selection criteria

Lancet

Lancet

Drug Alcohol Depend

Lancet Infect Dis

Int J Drug Policy

Int J Drug Policy

J Subst Abuse Treat

J Subst Abuse Treat

Lancet

Lancet

Lancet

2008 report on the global AIDS epidemic

Risk of HIV-1 transmission for parenteral exposure and blood transfusion: a systematic review and meta-analysis

AIDS

Absence of hepatitis C virus transmission in a prospective cohort of heterosexual serodiscordant couples

Sex Transm Infect

Heterosexual transmission of HIV-1 is associated with high plasma viral load levels and a positive viral isolation in the infected partner

J Acquir Immune Defic Syndr

Per-contact risk of human immunodeficiency virus transmission between male sexual partners

Am J Epidemiol

HIV and risk environment for injecting drug users: the past, present, and future

Lancet

HIV voluntary counseling and testing and behavioral risk reduction in developing countries: a meta-analysis, 1990–2005

AIDS Behav

Best-evidence interventions: findings from a systematic review of HIV behavioral interventions for US populations at high risk, 2000–2004

Am J Public Health

Effectiveness of interventions to prevent sexually transmitted infections and human immunodeficiency virus in heterosexual men: a systematic review

Arch Intern Med

A meta-analysis of the effect of HIV prevention interventions on the sex behaviors of drug users in the United States

J Acquir Immune Defic Syndr

Do prevention interventions reduce HIV risk behaviours among people living with HIV? A meta-analytic review of controlled trials

AIDS

Outcome, attrition, and family-couples treatment for drug abuse: a meta-analysis and review of the controlled, comparative studies

Psychol Bull

Long-term effects of an HIV/STI sexual risk reduction intervention for heterosexual couples

AIDS Behav

Effectiveness of peer education interventions for HIV prevention in developing countries: a systematic review and meta-analysis

AIDS Educ Prev

Preventing HIV infection among injecting drug users in high-risk countries: an assessment of the evidence

Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus transmission among injecting drug users: a review of reviews

Addiction

A review of the effectiveness and cost-effectiveness of needle and syringe programmes for injecting drug users

Condom effectiveness in reducing heterosexual HIV transmission

Cochrane Database Syst Rev

HIV prevention cost-effectiveness: a systematic review

BMC Public Health

Substitution treatment of injecting opioid users for prevention of HIV infection

Cochrane Database Syst Rev

Methadone maintenance at different dosages for opioid dependence

Cochrane Database Syst Rev

Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence

Cochrane Database Syst Rev

Decreasing international HIV transmission: the role of expanding access to opioid agonist therapies for injection drug users

Addiction

Sustained-release naltrexone for opioid dependence

Cochrane Database Syst Rev

Oral naltrexone maintenance treatment for opioid dependence

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Antidepressants for cocaine dependence

Cochrane Database Syst Rev

Dopamine agonists for cocaine dependence

Cochrane Database Syst Rev

Anticonvulsants for cocaine dependence

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Psychosocial interventions for cocaine and psychostimulant amphetamines related disorders

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Effectiveness of interventions for the prevention of HIV and other sexually transmitted infections in female sex workers in resource poor setting: a systematic review

Trop Med Int Health

Randomized controlled trials of individual-level, population-level, and multilevel interventions for preventing sexually transmitted infections: what has worked?

Series
Prevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed