HIV prevention, treatment, and care services for people

HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage.

Previous reviews have examined the existence of HIV prevention, treatment, and care services for persons who inject drugs worldwide, but they did not quantify the scale of coverage. Mathers and colleagues undertook a systematic review to estimate national, regional, and global coverage of HIV services in people who inject drugs. The authors did a systematic search of peer-reviewed (Medline, BioMed Central), internet, and grey-literature databases for data published in 2004 or later. A multistage process of data requests and verification was undertaken, involving UN agencies and national experts. National data were obtained for the extent of provision of the following core interventions for persons who inject drugs: needle and syringe programmes, opioid substitution therapy and other drug treatment, HIV testing and counselling, antiretroviral therapy, and condom programmes. They calculated national, regional, and global coverage of needle and syringe programmes, opioid substitution therapy, and antiretroviral therapy on the basis of available estimates of persons who inject drugs population sizes. By 2009, needle and syringe programmes had been implemented in 82 countries and opioid substitution therapy in 70 countries; both interventions were available in 66 countries. Regional and national coverage varied substantially. Australasia (202 needle-syringes per individuals who inject drugs per year) had by far the greatest rate of needle-syringe distribution; Latin America and the Caribbean (0.3 needle-syringes per individuals who inject drugs per year), Middle East and north Africa (0.5 needle-syringes per individuals who inject drugs per year), and sub-Saharan Africa (0.1 needle-syringes per individuals who inject drugs per year) had the lowest rates. Opioid substitution therapy coverage varied from less than or equal to one recipient per 100 persons who inject drugs in central Asia, Latin America, and sub-Saharan Africa, to very high levels in western Europe (61 recipients per 100 individuals who inject drugs). The number of persons who inject drugs receiving antiretroviral therapy varied from less than one per 100 HIV-positive persons who inject drugs (Chile, Kenya, Pakistan, Russia, and Uzbekistan) to more than 100 per 100 HIV-positive persons who inject drugs in six European countries. Worldwide, an estimated two needle-syringes (range 1-4) were distributed per persons who inject drugs per month, there were eight recipients (6-12) of opioid substitution therapy per 100 persons who inject drugs, and four persons who inject drugs (range 2-18) received antiretroviral therapy per 100 HIV-positive persons who inject drugs. Worldwide coverage of HIV prevention, treatment, and care services in persons who inject drugs populations is very low. There is an urgent need to improve coverage of these services in this population at higher risk from HIV.

Although the number of countries with core HIV prevention services (needle-syringe programmes [NSP], opioid substitution therapy [OST], and antiretroviral therapy[ART]) for people who inject drugs is growing, coverage is highly variable and it remains very poor in the majority of countries. Outside of sub-Saharan Africa, one-third of all HIV infections are acquired through injecting with contaminated equipment. Unless there is concerted action to address the risk environments that decrease the likelihood that sterile injecting equipment can be used, HIV transmission through injecting will continue to flourish. Rapid expansion of coverage for the 9 core interventions identified as essential by UNODC, WHO, and UNAIDS is urgently needed. In addition to NSP, OST, and ART, these are voluntary counselling and testing; prevention and treatment of sexually transmitted infections; condom programming for injecting drug users and partners; tailored information, education and communication; vaccination, diagnosis, and treatment of viral hepatitis; and prevention, diagnosis, and treatment of tuberculosis. New interventions are not needed, rather policies to increase implementation of proven HIV programmes clearly are – and that will require that policy-makers recognise that it is high time for rights-based, evidence-informed policies and programming.