Report Details Effective HIV Treatment for Drug Users

BANGKOK, Thailand—A new IHRD report, Breaking Down Barriers: Lessons on Providing HIV Treatment to Injection Drug Users, details successful efforts to offer drug users antiretroviral treatment (ARV) and the dangers of failure to do so.

The report was released during the XV International AIDS Conference in Bangkok, Thailand, at the satellite meeting "HIV Treatment for Drug Users: A Realistic Goal." That meeting, which called for greater inclusion of drug users in HIV treatment efforts, was organized by a coalition of leading international AIDS organizations including OSI's International Harm Reduction Development Program (IHRD), the Central and Eastern European Harm Reduction Network, the European AIDS Treatment Group, Gay Men’s Health Crisis, the Thai Drug Users’ Network, and the Thai AIDS Treatment Action Group.

Jim Kim, MD, director of the World Health Organization’s HIV/AIDS program, served as co-chair of the meeting. The meeting follows another consultation held in April that brought together WHO representatives with those from harm reduction networks from Central and Eastern Europe, Asia and Latin America to discuss strategies for increasing access to HIV treatment for drug users.

"Available data show clearly that drug users, offered proper support from the health sector, receive the same benefits from treatment as other people with HIV," Kim said at a press conference before the meeting. "Yet drug users are routinely written off as unreachable and noncompliant. In an increasing number of countries, failure to offer HIV treatment to drug users means that an effective response to the epidemic is being fatally compromised."

The Joint UN Programme on AIDS (UNAIDS) estimates that injecting drug use accounts for ten percent of annual HIV infections worldwide, as many as one of three new HIV infections outside Africa, and the driving force behind the world’s fastest growing epidemics. In Russia, as many as one million people have been infected with HIV in less than ten years, with over 80 percent of infections being among injecting drug users (IDUs). In China, more than 60 percent of the country’s one million estimated infections are among IDUs. All of the countries of Central Asia, and many in Southeast Asia and the Southern Cone of Latin America report that IDUs account for a majority of HIV infections or a rapidly growing share of total cases.

"The common assertion that drug users cannot comply with treatment represents a failure of vision by AIDS program administrators, not a description of reality," said IHRD program officer Konstantin Lezhentsev, MD, noting that the report described successful efforts to offer ARV to IDUs in Brazil, Argentina, and a number of urban settings in the United States and Europe. "Like exhausted single mothers, farmers in remote villages, or gay men in intolerant cultures, drug users find it easier to access treatment if offered specific approaches that recognize their needs. The question is whether governments and healthcare systems will step up to their responsibility to meet the specific needs of this group, or continue to simply deny treatment to drug-users based on the myths that are based more on prejudice and discrimination than on healthcare and human rights principles."

The OSI report notes both treatment shortfalls and promising developments, including:

• In Russia, where drug users accounted for 90 percent of cumulative HIV cases in 2002, AIDS service programs in St. Petersburg and Moscow reported that none of those on ARV were active IDUs in 2002. In Moscow, the head of the City AIDS center told the media that "there is little need for HIV medicines because drug-users are not eligible for treatment."
• In Ukraine, where drug users represent 70 percent of cumulative HIV infections, clinics reportedly treat children first, non-drug users next, and drug users last with antiretrovirals. Fewer than 20 percent of those on ARV were active IDUs in 2002.
• In Malaysia, injecting drug use accounts for 75 percent of HIV infections. Yet former IDUs made up only 20 percent of those receiving treatment in Kuala Lumpur in 2003, and none of those on ARV were active IDUs.
• A 2004 survey found that three of the four Latin American countries for which information on HIV prevalence among IDUs is available—Brazil, Chile, and Uruguay—offer ARV to eligible patients with HIV regardless of past history. The fourth, Argentina, offers ARV to former IDUs who were abstinent from drugs.
• IDUs had no access to ARV in the remaining 18 Latin American and Caribbean countries surveyed, including those like Colombia with as many as 8,000 HIV patients already on ARV.

Failure to offer HIV treatment to drug users has been justified in many developing countries by the extremely limited supply of medication available. But experts in Bangkok said that new developments like the formation of the Global Fund to Fight AIDS, TB and Malaria and the manufacture of generic drugs will sharply increase availability of antiretroviral therapy, without necessarily removing the discrimination the keeps drug users from treatment.

"Mechanisms like the Global Fund or WHO's 3 by 5 target are a source of excitement and great plans," said Mauro Guarinieri of the European AIDS Treatment Group. "But in many parts of the world, increased funds have not yet been matched by commitment to prioritise health care over punitive law enforcement. Unless governments act immediately to scale up not only HIV treatment for drug users, but also such interventions as methadone maintenance and needle exchange, the promise of AIDS treatment will be an empty one. What does it mean if we create an AIDS service structure in Asia or the former Soviet Union that systematically ignores the majority of those with AIDS?"

Coalition members also cautioned that overly punitive policies on illicit drugs influenced the course of HIV treatment, whether by forcing thousands of drug users into high-risk environments such as prisons and forced treatment centers or by penalizing such measures as possession of a clean syringe.

"While the world hails Thailand’s successes this week, we must also acknowledge the failures," said Paisan Suwannawong of the Thai AIDS Treatment Action Group. "Long after the government began receiving global praise for the manufacture of generics, drug users were on the list of those who were not eligible. The government has now committed to treating 70,000 people on treatment by 2005, but there is a danger that injecting drug users will not gain from this program because they will be afraid that police will take them from the clinics."

Speakers at the meeting and the report released by IHRD offered a number of steps to increase drug user access to ARV, including:

• Integration of HIV treatment and substance use treatment, so that clinics can provide ARV, opioid substitution programs, social counseling and other most needed services under a single roof;
• Simplified dosing, such as use of one-a-day ARV medications without dietary restrictions for drug users, and use of innovative approaches such as directly administered antiretroviral therapy (DAART);
• Educational efforts to reduce physician discrimination against and misperceptions about active and former drug users;
• Effective use of the experience of harm reduction programs and greater involvement of the community counselors and treatment educators;
• Addition of opioid substitution treatments such as methadone to WHO’s Essential Drug List; and
• Review of laws pertaining to drug use so that they do not compromise public health principles.

"There is evidence that treatment for drug users works," said the World Health Organization's Kim. "The question now is how to cure the discrimination that keeps them locked out of treatment."