Injection of hope

Wider implementation of harm-reduction programs may help curb HIV's spread

Alex Wodak, a physician in Sydney, Australia and former president of the International Harm Reduction Association, is thankful that his country responded rapidly to a growing HIV epidemic among injection drug users (IDUs). As a result only 5% of the country's new HIV infections in 2003 occurred within the IDU community. In the US that same year, 33% of new infections were among IDUs or their sex partners.

This discrepancy in HIV prevalence among IDUs between the two countries can be at least partly attributed to the introduction of harm-reduction programs that aim to reduce the spread of HIV among IDUs. The package of programs includes education, needle or syringe exchange so that IDUs aren't injecting with contaminated needles, supervised injection facilities that provide both clean needles and help prevent overdose, and drug replacement therapy to help wean individuals from the addiction of illegal drugs.

Studies show that these programs are an effective way to reduce HIV transmission among this highly vulnerable group. This has positive effects well beyond IDUs. Researchers have observed that more generalized HIV epidemics in several countries often start among IDUs, so reaching this population can have a much broader impact on HIV prevention efforts.

These programs also establish a vital link between public health workers and IDUs, who are often isolated. "Needle and syringe programs are a stand-in for the larger issue of how to reach the people who are the least engaged in society yet are at the greatest risk," says Daniel Wolfe, the deputy director of International Harm Reduction Development Program at the Open Society Institute. Yet harm-reduction programs are not implemented widely because drug use is a difficult issue to confront. There are legal and moral sensitivities about drug use, just as there are around the sexual transmission of HIV. "Thank God that Australia was settled by convicts, whereas the United States was settled by puritans and has been dealing with it ever since," says Wodak.

Because of their high risk, IDUs can also be important volunteers for AIDS vaccine trials. But it is an ongoing question whether it is ethical to test vaccine candidates in IDU cohorts without providing sterile needles and syringes.

A growing problem

The HIV epidemic among IDUs is a serious problem. Globally, 10% of all HIV-infected individuals are IDUs and, outside of sub-Saharan Africa, an estimated one in three new HIV infections is due to injection drug use.

Even in Africa, where the epidemic has been driven almost exclusively by sexual transmission, injection drug use is now a documented source of HIV transmission in 10 countries. Contaminated needles cause the largest share of new infections in some 20 nations and are fueling several of the world's growing epidemics, including those in Russia, Ukraine, China, Indonesia, central Asia, and much of south and southeast Asia. In the countries of the former Soviet Union roughly 70% of HIV infections occur among IDUs.

These alarming statistics highlight the overwhelming need for harm-reduction programs, especially in areas with exploding epidemics. A comprehensive approach is required to combat the spread of HIV within communities of IDUs, including programs to reduce the number of individuals who inject drugs, promote safe injection practices and discourage unsafe sex, and roll back the legislation that outlaws the sale or possession of injection paraphernalia.

Some of the most well-studied of these programs, and of HIV prevention strategies overall, are needle and syringe provision or exchange programs that supply IDUs with sterile injection equipment. These come in a variety of forms, including supervised injection sites, a one-to-one exchange of needles, or sale of sterile needles and syringes at pharmacies, clinics, or vending machines. The majority of studies have shown that needle and syringe programs reduce HIV transmission in a safe manner and are very cost-effective.

Since the first needle-exchange program began in Edinburgh, Scotland, in the early 1980s, many such programs have started up around the globe. There are now safe injection facilities operating in over 20 European cities. These sites provide IDUs with clean injection equipment and allow them to inject drugs in a supervised setting. These sites also usually offer education and condoms, access to drug rehabilitation, and health services, and are able to connect IDUs with a larger support network that can influence positive behavior change. There is currently only one safe injection site in North America. This site in Vancouver, Canada, opened in 2003 and was recently given permission by the Canadian government to continue operating until at least the end of next year.

US opposition

Despite the evidence in support of needle and syringe provision as an effective HIV prevention strategy, the programs are still reaching a miniscule number of people. In 2004 HIV prevention activities for IDUs reached at most 5% of all users globally.

This is partly due to the US's opposition to needle and syringe exchange programs, both at home and abroad. As the largest provider of funds for international AIDS prevention programs, the US also has great sway over programs in other countries. Restrictions in the President's Emergency Plan for AIDS Relief (PEPFAR) prevent any of the US$34 million from being used to fund needle-exchange programs. The US government's stance stems from concerns that providing people with injection equipment will only promote illegal drug use.

Within the US, several states have found ways around the federal funding ban and operate needle and syringe programs using state and local government funding, or private donations.

Implementation

One challenge in needle syringe programs is determining how many needles are enough to stem HIV transmission. The World Health Organization (WHO) approximates that providing 200 sterile needles and syringes per drug injector each year is likely to control the spread of HIV. Another often quoted target accepted by a range of agencies, including the WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS), is that 60% of all injections need to be done with a sterile needle and syringe. Australia established its first needle and syringe program in 1986 and annually distributes 30 million needles in a country with a population of less than 20 million. By contrast, the US distributes only about 25 million needles each year for a population of 300 million.

Implementing these programs early in the course of an HIV epidemic is also critical to success. For many countries in Eastern Europe and southeast Asia, therefore, the optimal time to implement such programs is now. According to UNAIDS, Russia's HIV epidemic is the fastest growing in the world. Most infected individuals are under the age of 30 and nearly 90% are IDUs, yet needle and syringe programs reach perhaps 2% of the Russian IDU population. Most of these are funded by non-governmental organizations (NGOs). Moscow has no needle-exchange program, syringes are not available for purchase, and possession of a syringe containing drug residue is a punishable offense.

Other former Soviet states have more progressive drug policies. Ukraine hosts about 250 projects sponsored by the Global Fund that reach about 70,000 IDUs. Among the central Asian countries of the former Soviet Union, where about 70% of the HIV infections are among IDUs, only Kyrgyzstan and Tajikistan offer drug treatment and needle and syringe programs.

China has also made recent strides in its commitment to stemming the HIV epidemic among IDUs, which make up about 44% of the 650,000 people officially estimated to be HIV infected. The Chinese government plans to spend approximately $185 million on HIV prevention, doubling current spending, between 2005 and 2007. Over the next five years, the Global Fund also plans to disburse more than $60 million in funds to prevent HIV transmission among IDUs and sex workers in the seven Chinese provinces that harbor 90% of the HIV-infected IDUs.

Indonesia, a country with strict drug laws, is making attempts to stem its injection-driven HIV infection rate of 44%. Vietnam made a strong national commitment in 2005 to provide sterile needles and drug substitution therapy for its IDUs, which make up 52% of the nation's total number of HIV-infected individuals. Despite this, harsh anti-drug laws have resulted in the executions of 44 people in 2004, according to Amnesty International. UNAIDS estimates that more than 55,000 drug users are currently held in rehabilitation centers in Vietnam that human rights activists say more closely resemble labor camps.

Vaccine trials

IDUs would benefit greatly from access to a preventive AIDS vaccine and so their participation in clinical trials is especially important. Many trial sponsors and researchers agree that if IDUs are enrolled in a vaccine trial, the sponsor is ethically required to provide the volunteers with sterile injection equipment. "Needles and syringes should obviously be provided. It is good research ethics and good public health," says Chris Beyrer, director of the Fogarty AIDS International Training and Research Program at Johns Hopkins Bloomberg School of Public Health.

The Thai Drug Users Network (TDN) is an activist group that has lobbied for the provision of sterile needles and syringes to IDUs participating in HIV prevention trials in the country, many of which are sponsored by US-based organizations. So far they have been unsuccessful and the TDN has now taken their case to the Thailand National Human Rights Commission.

A number of other cervical barriers are also in the process of being developed and approved. The single-sized Lea's Shield is a silicone cervical barrier contraceptive already approved by the US Food and Drug Administration for up to 48 hours of continuous use. Another product being tested, the BufferGel Duet, is a disposable, one-size diaphragm pre-filled with the candidate microbicide and contraceptive BufferGel.

Needles and syringes are available for purchase at pharmacies in Thailand but, according to Karyn Kaplan of TDN, the drug users her group talks with say that obtaining needles is not that easy. They cost about 12 cents each and many pharmacists refuse to sell needles to people they perceive as drug users. "Clearly the US policies against needle exchange and harm reduction itself are hampering individuals' ability to protect themselves," says Kaplan. Since the US is not likely to begin funding needle and syringe programs in the near future, Beyrer suggests that an NGO could provide them.

Researchers agree that enhancing the ease of access to clean needles and syringes will help IDUs protect themselves and their partners, and perhaps help head off some of the world's rapidly expanding epidemics.