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

Injecting drug use

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

The authors systematically reviewed reports about determinants of HIV infection in injecting drug users from 2000 to 2009, classifying findings by type of environmental influence. They then modelled changes in risk environments in regions with severe HIV epidemics associated with injecting drug use. Of 94 studies identified, 25 intentionally examined risk environments. Modelling of HIV epidemics showed substantial heterogeneity in the number of HIV infections that are attributed to injecting drug use and unprotected sex. Strathdee and colleagues estimate that, during 2010-15, HIV prevalence could be reduced by 41% in Odessa (Ukraine), 43% in Karachi (Pakistan), and 30% in Nairobi (Kenya) through a 60% reduction of the unmet need of programmes for opioid substitution, needle exchange, and antiretroviral therapy. Mitigation of patient transition to injecting drugs from non-injecting forms could avert a 98% increase in HIV infections in Karachi; whereas elimination of laws prohibiting opioid substitution with concomitant scale-up could prevent 14% of HIV infections in Nairobi. Optimisation of effectiveness and coverage of interventions is crucial for regions with rapidly growing epidemics. Delineation of environmental risk factors provides a crucial insight into HIV prevention. Evidence-informed, rights-based, combination interventions protecting persons who inject drugs’ access to HIV prevention and treatment could substantially curtail HIV epidemics.

For abstract access click here

Editors’ note: This paper begins with a systematic review of the existing literature on drug injecting and HIV risk to see to whether research conducted since 2000 has explored the extent to which physical, social, economic, and political environments interact with micro-environmental and macro-environmental factors to confer risk or protection for HIV infection among people who inject drugs. Examples are provided of micro- and macro-environmental physical, social, economic, and political risk factors for HIV infection. Mathematical modelling is then used to estimate the influence of the environment and the potential impact of overcoming environmental impediments to optimal HIV prevention, treatment, care and support. The synergistic effects of reducing unmet need for clean injecting equipment, opiate substitution treatment, and antiretroviral treatment by 60% are modelled for two cities with serious epidemics among people who inject drugs (Odessa, Ukraine and Karachi, Pakistan) and one city with an emerging drug-related epidemic (Nairobi, Kenya). The findings are striking and compel policy change, including promoting the health and recognising the human rights of people who inject drugs. Shifting the focus from individuals to their social and political contexts helps shine light on the social and political institutions involved in harm production. This risk environment approach to epidemiology should be applied to other settings and other populations at risk of HIV infection as a keystone of combination prevention.