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HIV Prevention, Harm Reduction & Injecting Drug Use

Injecting drug users (IDUs) have been among the groups most affected by HIV & AIDS since the epidemic began. Sharing syringes is a very efficient way to transmit blood-borne viruses such as HIV, which can spread rapidly through IDU populations. The sharing of needles and “works” (syringes, water, mixing spoon, etc.) is thought to be three times more likely to transmit HIV than sexual intercourse. ¹

Recreational drug use is illegal in most parts of the world and attitudes to HIV prevention for IDUs vary significantly. It is estimated that there were 13.2 million injecting drug users globally at the end of 2003. ² Around 10% of HIV infections globally are directly a result of transmission through injection. ³ The worst affected areas for infection through contaminated needles are Eastern Europe, Central Asia, most of Southern Asia, North Africa, Iran, Pakistan, Nepal, and parts of Latin America. ⁴

It should be noted that injecting drug use is not the only form of recreational drug use that increases the risk of HIV transmission; non-injecting drug users can be exposed to the virus through unsafe sexual behaviour whilst intoxicated, as explained in our recreational drug use & HIV page.

Rates of injecting drug use and HIV in selected countries

Country	Proportion of population who are IDUs (%)	HIV prevalence (%) in IDUs
		National	Capital city	Other sites
Argentina	0.17	18.8-39.2	7.6-80.0	60.0-61.0
Brazil	0.69	28.0-42.0	15.0-34.0	18.0-48.5
Bermuda & Caymans	4.93	-	-	-
Canada	0.61	14.5-47.9	7.1-23.5	1.1-41.0
China	0.23	0.0-80.0*	-	1.0-84.0*
Estonia	2.05	13.0	41.0	-
France	0.26	13.6-19.3	-	13.7
India	0.21	1.3-68.4	44.5-45.0	2.0-81.0
Indonesia	0.42	15.0-47.0	14.9-40.0	16.0-56.0
Italy	0.64	10.0-65.6	-	0.6-32.8
Libya	0.23	0.5-59.4	-	-
Malaysia	1.47	10.0-40.0	-	18.0
Myanmar	0.71	37.1-63.0	37-38.9	7.0-92.3
Poland	1.45	6.3-11.0	16.9	-
Portugal	0.45	13.6	8.3-41.3	0.0-37.0
Puerto Rico	0.59	-	42.4-55.2	-
Russia	1.96	0.8-4.8	0.12-28.3	0.0-64.5
Spain	1.06	15.2-66.5	-	1.3-48.3
United Kingdom	0.26	0.8	2.9-4.5	0.2-3.3
USA	0.67	-	-	0.4-42.0

* Excluding Hong Kong and Macao

Around 25% of all injecting drug users live in South and South-east Asia, and a further 18% in East Asia. Both China and India are home to more than a million IDUs. Asia has the world's highest rates of HIV infection among IDUs. By 1999, drug-dependent individuals comprised about 77% of HIV infections in Malaysia and 69% in China, and 66% of AIDS cases in Viet Nam.

A further 24% of injecting drug users are found in Eastern Europe and Central Asia. There are around 2 million in Russia, 397,000 in Ukraine and 174,000 in Kazakhstan. IDUs account for 82% of all HIV/AIDS cases in Central Europe and Former Soviet Union states.

North America and Latin America respectively account for 10.6% and 7.6% of injecting drug users. There are around 1.3 million in the USA, 800,000 in Brazil and 153,000 in Canada.

Around 9.4% of IDUs live in Western Europe, where populations above 200,000 exist in Germany, Italy and Spain.

Types of prevention

There are three approaches to HIV prevention among IDUs. Supply reduction and demand reduction are the most favoured and commonly used, relying on enforcement and education to prevent drug use. The third approach, known as ‘harm reduction’, was pioneered in Western Europe in the mid 1980s, but is still considered controversial in many parts of the world. Evidence, however, suggests that a combination of all three methods of prevention is the most effective way to decrease HIV infection through injecting drug use.

Supply reduction

This method of prevention is practised globally against all forms of illegal drug use. It focuses on halting the drug supply routes by:

• Seizing illegal drugs through customs operations.
• Arresting drug trafficking groups to break up supply routes through law enforcement.
• Encouraging producers of drug crops, such as opium poppies, to grow alternative crops.

When used alongside the other two approaches, supply reduction can be effective in limiting the quantity of drugs available on the street. This results in higher street prices, which may dissuade some people from drug use.

Demand reduction

This is a popular and effective form of prevention that promotes a healthy lifestyle free from drug use. It aims to decrease the demand for drugs, and may be achieved by:

• Education in schools about the damaging effects of drug use.
• Reaching out to the general population through awareness campaigns.
• The rehabilitation of drug users through clinics, using techniques such as methadone substitution treatment to decrease dependency on narcotics such as heroin. This approach also contributes to harm reduction.

Harm reduction

Harm reduction focuses solely on minimising harm caused through drug use and preventing the spread of HIV, without condoning or prohibiting continued drug use. It defines policies, programmes, services and actions that work to reduce drug-related health, social and economic harms to individuals, communities and society that are associated with the use of drugs.

“Harm reduction is pragmatic: it accepts that the use of drugs is a common and enduring feature of human experience, and acknowledges that, while carrying risks, drug use provides the user with benefits that must be taken into account if responses to drug use are to be effective.

“Harm reduction recognises that containment and reduction of drug-related harms is a more feasible option than efforts to eliminate drug use entirely. Harm reduction does not focus on abstinence: although harm reduction supports those who seek to moderate or reduce their drug use, it neither excludes nor presumes a treatment goal of abstinence.” - UK Harm Reduction Alliance. ⁵

A harm reduction approach will often include the following:

• Needle exchange programmes provide places where drugs users can exchange used needles and syringes for new, clean ones, and so reduce the risk of HIV infection through sharing equipment. They may also provide other treatment and care services such as HIV testing, referral routes to rehabilitation programmes, counselling, and condoms.

• Rehabilitation clinics provide many services such as counselling and detoxification treatments to help drug users to stabilise their behaviour. Methadone or buprenorphine substitution treatment, prescribed in liquid or pill form, removes the risk of HIV infection through needle use. This detoxification approach gives users a chance to manage the physical and psychological effects that occur through prolonged opioid use, whilst gradually decreasing dependency. Substitution treatment also stops IDUs from using dangerous street drugs that can be contaminated.

• Community-based outreach programmes work with IDUs to distribute clean equipment, promote condom use and provide information about prevention and rehabilitation. Injecting communities are often secretive and distrustful of authorities. Outreach programmes focus on accessing these hidden groups, opening an important route to providing support. In some cases, former IDUs are recruited and trained as peer-outreach workers. Some IDUs are likely to be involved in the commercial sex-trade to fund expensive drug addiction, so sexual health information and condom promotion are key factors in preventing HIV transmission through other routes.

Some harm reduction programmes also include safe injection rooms that provide services for problem IDUs who are unable to change their behaviour through other harm reduction treatments. These services aim to “medicalise” injecting drug use by giving it a cold, sterile image and studies have shown them to be effective in making opioid use unattractive to young potential users. ⁶

The effectiveness of harm reduction

There is clear evidence that needle exchange programmes (NEPs) have reduced HIV transmission rates among IDUs in areas where they have been established. One of the most definitive studies of NEPs was carried out in 1997, focusing on 81 cities worldwide. It found that HIV infection rates increased by 5.9% per year in the 52 cities without NEPs, and decreased by 5.8% per year in the 29 cities that did provide NEPs. ⁷

Other evidence includes an eleven-year study of HIV among IDUs in New York, which found that HIV prevalence fell from 54% to 13% following the introduction of NEPs. ⁸

The World Health Organisation (WHO) released a report in 2004 that reviewed the effectiveness of NEPs in many countries, and whether they promoted or prolonged illicit drug use; the results produced convincing evidence that NEPs significantly reduce HIV infection, and no evidence that they encourage drug use. ⁹

Drug substitution treatment has proven effective in rehabilitating and stabilising IDUs, ¹⁰ and in reducing HIV infection rates. For example, researchers from the University of Philadelphia monitored 152 injecting users receiving methadone maintenance treatment and 103 injecting users on no treatment over a period of 18 months, all of whom were HIV negative at the beginning of the study. The results showed that over the 18 months, only 3.5% of those on treatment became infected with HIV, as opposed to 22% not on treatment. ¹¹

Another study in Amsterdam followed a group of 582 IDUs on methadone maintenance treatment for an average of three years. The HIV infection rate was 6.0 per 100 person-years among those who continued injecting throughout the treatment, and 0.2 per 100 person-years in those who stopped injecting while on treatment. These results indicate that oral methadone treatment is critical in stopping drug users injecting, though a small minority will later revert to high-risk behaviour. ¹²

A report by the WHO in March 2005 reviewed many global studies and concluded that substitution treatment is a ‘critical component’ of HIV prevention policy, significantly reducing opioid dependency and HIV infection rates. ¹³ In addition, studies have also found a decline in crime rates and commercial sex work when IDUs no longer have to find ways to fund their expensive addictions. ^{14 15 16}

Community-based outreach prevention focuses on promoting a change in high-risk behaviour. Educating users about HIV prevention, helping them to get into rehabilitation programmes, and tackling the issues of IDUs and sexual transmission, are all part of outreach prevention. ¹⁷ A report from the WHO reviewed data from over 40 studies on outreach prevention and concluded that outreach prevention methods significantly reduce high-risk behaviour in IDUs and are successful in directing them to rehabilitation services. ¹⁸

In 2006, UNAIDS published a report that reviewed several 'high coverage' harm reduction programmes in transitional and developing countries. The results found that reaching a high percentage of IDUs was possible (over 50% of local IDU population) as long as some key factors were met. ¹⁹

The controversy of harm reduction

Harm reduction has been surrounded by controversy since the mid 1980s when needle exchanges and substitution treatments were first introduced in Western Europe. Social and political attitudes on how to tackle drug use differ greatly. All governments promote drug use prevention through supply and demand reduction techniques. However some politically conservative countries do not agree with some elements of harm reduction on the principle that providing clean equipment or methadone encourages drug abuse.

The arguments against harm reduction range from moderate to extreme. Some believe that needle exchange services are a waste of money and only promote injecting drug use, when the message should be abstinence from drugs. Substitution drug treatment is a difficult concept for many to accept; critics argue that this prolongs drug addiction or provides users with drugs to sell on the street to fund further drug use. Although outreach work is the most accepted form of harm reduction, some believe it makes life easier for drug users by teaching them safer methods of injecting, and is overall a waste of resources. There is also strong opposition to safe injection rooms and heroin prescription for problem IDUs, which are the most contentious forms of harm reduction.

The United States government provides no federal funding for needle exchange services, ²⁰ and also refuses to fund needle exchanges in other countries. In Russia, substitution treatment programmes are illegal, and support for needle exchanges is very limited. Yet some other countries that have traditionally opposed harm reduction – such as China, Malaysia and Iran – have recently changed their viewpoints and begun to scale up services.

More about global attitudes to prevention methods can be found in our HIV prevention around the world page.

Conclusion

The future of HIV prevention for IDUs in many countries remains uncertain. The evidence for the effectiveness of harm reduction is overwhelming, yet in many parts of the world authorities refuse to implement such programmes for political or moralistic reasons. Whilst this situation remains, it seems inevitable that the spread of HIV among IDUs will continue to outpace attempts to control it.

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