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People Who Inject Drugs and HIV/AIDS
Introduction to drug use and HIV
Blood transfer, through the sharing of drug taking equipment, particularly unsterilised needles, carries a high risk of HIV transmission. Around 30 percent of global HIV infections outside of sub-Saharan Africa are caused by injecting drugs, and it accounts for an ever growing proportion of those living with HIV. 1 HIV transmission is a risk when taking drugs by means other than injecting, but people who inject drugs (PWID) have the highest risk.
The illegal nature of injecting drugs can also create barriers to accessing adequate HIV prevention, testing and treatment services, making people who inject drugs more vulnerable to HIV and its effects. Without adequate access to these services, there is a high risk that HIV will also be transmitted to sexual partners. 2 The crossover of drug use with sex work means that HIV is more likely to be transmitted to other at-risk populations and their partners.
Drugs can be taken in a variety of ways including drinking, smoking, snorting and rubbing, but it is the injection of drugs that has the biggest risk of HIV transmission.
HIV prevalence among people who inject drugs
It is estimated that there are around 15.9 million PWID worldwide; 47 percent of this population are from just five countries: China, Vietnam, Malaysia, Russia and Ukraine. 3 The number of PWID by region are as follows: 4
South, East, and South-East Asia - 4.5 million, Russia, Eastern Europe and Central Asia - 3.7 million, North America - 2.3 million, Latin America - 2 million, Sub-Saharan Africa - 1.8 million, Western Europe - 1 million, Middle East and North Africa - 300,000 - 1 million, Caribbean - 186,000, Oceania - 170,000.
Globally around 3 million, or 13.1 percent, of PWID are living with HIV. 5 However only 4 percent of these people are receiving antiretroviral treatment. 6 Among the regions where HIV prevalence among people who inject drugs is high are: 7
- Estonia: between 54-90%
- Russia: 37%
- Ukraine: 22%
- Moldova: 16%
- Tajikistan: 16%
- Indonesia: 36%
- Pakistan: 27%
- Cambodia: 24%
- Myanmar: 22%
- Thailand: 22%
What is injected?
The most commonly injected drugs are heroin and other opiates, cocaine and amphetamines; the prevalence of each varies according to location and population group. In Western European nations, heroin is the most commonly injected drug amongst older users, whilst amphetamine-type stimulants (ATS) are favoured by younger people. ATS are also the most commonly injected drugs in Thailand, Laos, South Korea, Cambodia and Japan, whilst across Latin America (with the exception of Mexico), cocaine is the most commonly injected drug. 8 9 Cocaine injections occur more frequently among users due to the drug’s shorter lasting effect, thereby increasing the risk of HIV transmission.
A new drug named 'hagitat' caused an outbreak of HIV infections in Israel during 2012-2013. Drug users switched from injecting heroin to injecting hagitat, which has more sociable effects, and needs more 'hits' per day, leading to higher numbers of people sharing needles. 10
The use of image and performance enhancing drugs (IPEDs) is rising rapidly, especially in more developed nations such as the UK. 11 IPEDs are used to change one’s image, and increase one’s level of performance. A specific study in the UK found that HIV prevalence among men who inject IPEDs was similar to those who inject drugs like heroin and cocaine. This highlights that it is the injecting practice itself that is important to monitor, rather than the type of substance injected. 12 13 14
Why do some people inject drugs?
The United Nations Development Programme on HIV suggest the following reasons as to why people inject drugs rather than using other methods:
- greater availability of drugs that can be injected
- cheaper cost
- more rapidly acting
- none of the drug becomes lost in smoke
- production locations and trafficking routes
- migrating drug users sharing knowledge and techniques 15 16
- law enforcement - this has reduced supply, boosted the cost, and made injecting a more economically viable method of consumption. 17
Populations in developing nations have become more exposed to new methods of drug taking, including injecting, as refinement of drugs into injectable forms has been moved from more developed nations and closer to primary production areas. 18 One HIV-positive drug user in Pakistan described the scarcity and growing cost of heroin as the primary reason for switching from inhaling to injecting:
"Good-quality heroin is not available in the market anymore. There is low-quality heroin available at unaffordable prices. If we inject the low-quality heroin, its effects are immediate and prolonged."
Why are people who inject drugs at risk of HIV transmission?
Between five and ten percent of new HIV infections worldwide result from sharing used needles, with this figure jumping to 80 percent in Eastern Europe and Central Asia. 19 20 Injecting drug users are also more likely to test for HIV late; the chance of onwards HIV transmission via sharing needles is especially high until treatment is accessed.
However, sterile syringes are not always readily available, especially in countries with no/low roll-out of needle and syringe exchange programmes (NSPs). A lack of awareness or education about safe injecting is another major reason for sharing needles. Other possible reasons are that it is a social and cultural norm, and that it can act as a form of bonding.
Drug paraphernalia laws in some countries make it an offence to distribute or possess syringes for non-medical purposes:
- Mexico - a link has been found between arrests for carrying used or unused syringes, despite this being legal, with incidences of syringe sharing. 21
- Russia - higher rates of needle sharing among PWID have similarly been associated with arrests for drug offences. 22
- Scotland - Edinburgh prohibited the possession of syringes in 1981, and by 1984 HIV prevalence among PWID in the city was 50 percent. In contrast, Glasgow legalised syringe possession and HIV prevalence remained between 1-2 percent. 23
- Manipur, India - one person who injects drugs in this Indian state (where police can stop and search any suspected drug user), described fear of the law as a factor in needle sharing:
“When we [inject] drugs we need to be quick. Police might come at any time. For that reason... we don’t mind sharing with others." 24
It is suggested that the recent economic downturn caused more people in certain European Union (EU) states to turn to drug use, and cheaper ways of taking the drugs such as by sharing needles with others. There was also a stagnation in the HIV responses of some of these EU states. The combination of these two effects led to HIV outbreaks among PWID, in places such as Greece and Bulgaria during 2011. 25
Gender specific barriers
In many cases, women are more susceptible to HIV infection because of gender based violence (GBV); women may be pressured to share needles and engage in high-risk sexual activities. Women (especially mothers), are also more likely to conceal their drug taking behaviour because of societal discrimination, limiting their access to medical care and HIV services. 26
Reducing HIV transmission among people who inject drugs
Combination HIV prevention
Reducing HIV transmission among PWID needs a combination of approaches such as:
- stopping addictophobia - PWID face serious discrimination from a multitude of sectors of society, including a lack of inclusion in medical trials. Including PWID in research is important in the global HIV response.
- stopping apathy - much of society is indifferent to the rights of PWID; they must be shown the same human rights as others.
- stopping inattention - PWID are too often categorised as one group. HIV prevention initiatives must focus on subgroups such as females who use drugs or young people who use drugs. 27
Access to mental health services, sexual health checkups and condoms are also necessary. Alongside these, harm reduction measures are needed such as needle and syringe exchange programmes (NSPs), and opioid substitution therapy (OST). Libya lacks competent harm reduction policies, and 87 percent of PWID in 2010 were living with HIV. Efforts need to focus on prevention rather than simply awareness. 28
Harm reduction programmes
Legalising and enforcing harm reduction methods, engaging PWID in the HIV response, and investing funding and focus towards this population, are essential to implementing effective HIV prevention and treatment services. Here are some examples of successful harm reduction approaches for PWID:
- Kazakhstan have invested in needle and syringe exchange programmes since 1997, resulting in very low levels of HIV prevention among PWID. This has continued to drop year on year, from 3.8 percent in 2012, to 2.8 percent in 2013.
- The Tanzanian government has responded to high HIV prevalence among PWID by rolling out NSPs and opioid substitution therapy (OST). Engaging in this population has allowed service providers, (such The Tanzanian Network of People Who Use Drugs) to deliver prevention information directly to PWID.
- The Malaysian government is active in reducing injecting drug use, by implementing harm reduction programmes since 2005. All previously compulsory drug treatment centres are now voluntary, free and confidential. However the penalties for drug use remain harsh. 29
Low dead-space syringes
Syringes that are used to inject drugs contain either a high, or a low 'dead-space' area, which is where fluid (including blood) collects after injecting. High dead-space syringes are often preferred because they are cheaper, come with detachable needles, and are more readily available. However, low dead-space syringes collect 1000 times less fluid and therefore 1000 times less HIV copies, meaning HIV cannot survive very long in this type of syringe. The risk of HIV infection is reduced if someone used a low dead-space syringe after a HIV-positive person. Unfortunately, access to low dead-space syringes is sparce; they need to be better supplied and rolled out among NSPs and pharmacies. 30
Pre-exposure prophylaxis (PrEP) is a course of antiretroviral (ARV) drugs taken before possible exposure to HIV. Studies have been conducted into the potential use of PrEP for PWID. In Bangkok, Thailand, the use of Tenofovir reduced HIV transmission by 49 percent. 31 However, studies such as this one are rare, and the World Health Organisation (WHO) does not yet recommend PrEP for people who inject drugs. 32 33
People who inject drugs and discrimination
The 'war on drugs' approach forces people who inject drugs away from HIV services which may otherwise help to curb HIV transmission among this key population. Incarcerating drug users likewise fuels HIV transmission, especially in overcrowded prisons where syringe sharing and unprotected sex is more common. 34 It is thought that 56-90 percent of drug users will be imprisoned at some point in their life. 35
Laws which restrict PWID access to HIV services:
- prohibiting antiretroviral treatment (ART) for HIV-positive people who inject drugs
- prohibiting the provision of sterile injecting equipment
- criminalisation of drug possession and use. 36
Laws which allow PWID access to HIV services:
- harm reduction, although only 97 countries currently support some form of harm reduction approach
- opioid substitution therapy (OST)
- needle and syringe exchange programmes (NSPs)
- decriminalising drug possession. 37
Injecting drugs for purposes not prescribed by a doctor is illegal worldwide, and the criminalisation of drug use and possession can hinder attempts to engage people who use drugs with available HIV services. There have been documented incidences of Ukrainian police arresting and beating people near needle exchanges for possessing used and sterile syringes. 38 Police in Thailand have reportedly acted similarly despite possession of syringes being legal in the country. 39 It is estimated that 40 percent of countries have laws that interfere with the ability to reach people who inject drugs. 40
People who inject drugs who find themselves on the wrong side of the law, and in confrontation with the police may be distrustful of the authorities in general and hesitate to seek treatment or take advantage of prevention initiatives in the first place. Injecting drug users in some Eastern European and Central Asian countries are recorded on 'drug registers' and sometimes never removed from this list, denying them rights such as employment, parenthood or travel. 41
Young people who inject drugs
A report by the UNAIDS Inter-Agency Task Team on HIV and Young People found an estimated 70 percent of the world's drug users are under 25, and at least half in urban areas start injecting in their teens. 42 Of these young people, 3 percent are living with HIV. 43 Young people are also likely to show more high-risk behaviour such as sharing needles or getting needles from unofficial places. 44
HIV prevention programmes typically overlook young people at risk of injecting drug use; few reach out to vulnerable youth to prevent them from starting to inject or help them to end their addiction if they have already started. Moreover, prevention programmes do not specifically address the issues that vulnerable young people face, such as peer pressure, unstable family homes or exclusion from school. Some HIV prevention initiatives like opioid substitution may even deter young people because they require registration, parental consent or impose age restrictions. 45
Crack use and HIV among people who use drugs
Though crack, which is derived from cocaine, is normally smoked, it too presents a range of risk factors related to HIV. Some crack smokers suffer from burns, blisters and cuts on the lips and inside the mouth caused by the intense heat from the vaporising smoke being conducted through poorly constructed smoking devices. Blood from these wounds can contaminate the ‘stem’ - usually a small metal pipe - and be passed on to the next smoker. If two smokers both have open sores then there is a risk of HIV or hepatitis C transmission. Oral sex may also present a low risk for heavy crack-cocaine smokers who have open oral sores. 46 Like many drugs, crack cocaine usage can lead to risky sexual behaviour. 47
Crack cocaine is also more associated with marginal and at-risk groups including those who have turned to sex work to fund their addiction. In a group of drug users in South Florida, 48 percent of women who smoked crack, and 54 percent of women who both smoked crack and injected drugs, had traded sex for money or drugs, compared with 29 percent who only injected. 48
People who use drugs and sex work
Although people who inject drugs constitute a key group in themselves, there is also an overlap between drug addiction and those involved in sex work. Individuals who fall into both categories are particularly vulnerable to HIV. The link between substance abuse and sex work is hard to pinpoint though there are a variety of factors that are common to both including homelessness, unstable family lives, socio-economic deprivation, disrupted schooling, poor local authority care and a lack of confidence and self-esteem issues. 49
One study of UK cities found 63 percent of people who sold sex outdoors did so mainly to pay for drugs. Heroin was the most commonly used drug, with 78 percent having used it, and just under half the sample had injected drugs in the previous month. 50 UNAIDS believes that the spread of HIV in several North African and Middle Eastern countries is being facilitated by a combination of injecting drug use and sex work, with one third of PWID having paid for or sold sex. In Syria, 53 percent of drug users have sold sex, with 40 percent of these saying they had never used condoms. 51 One study of Sichuan province, China, reported similar rates with 56 percent of females who inject drugs selling sex. 52
Looking at the spread of HIV among these two risk groups in Jakarta, Indonesia, the Commission on AIDS in Asia found that infection levels began to increase within commercial sex networks only after the epidemic among people who inject drugs had reached significant levels. 53
Sexual risk behaviour related to drug use should not just be considered within the bounds of sex work. HIV transmission may be facilitated among drug users and their sexual partners if the drug user is sexually stimulated or disinhibited by drugs.
Antiretroviral treatment for people who use drugs
Access to antiretroviral treatment (ART) for PWID is surrounded by controversy and stigma in many parts of the world, despite the fact that people on treatment greatly reduce their chance of onwards HIV transmission (the treatment as prevention approach). Many governments favour policies that require absolute abstinence from illegal drug use before ART is provided. There are questions over whether heroin and crack cocaine users will respond to treatment as well as other patients, with studies both affirming and contradicting this view. 54 55
The second problem that drug users face is the interaction between recreational drugs and antiretroviral drugs. Recreational drugs can either speed up or slow activity of the liver which breaks down ARV drugs. This means the HIV suppressing effect of ARV treatment can be exhausted sooner than expected or will not work as rapidly as possible. 56 The higher likelihood of HIV and hepatitis C co-infection among PWID also leads to greater morbidity and mortality. 57
One study found that people who inject drugs whilst on antiretroviral treatment have lower viral suppression of HIV (56-58 percent) than those who do not inject (89 percent). Supporting people to adhere to their treatment (taking ARVs at the same time every day at least 95 percent of the time) among PWID is therefore an essential part of ensuring treatment is successful. 58
What needs to happen?
With injecting drug use accounting for a very significant proportion of people living with HIV, a combination of accessible HIV prevention approaches are needed to reduce HIV transmission among people who inject drugs. 59
Harm reduction measures including needle exchange programmes and opioid substitution therapy should be implemented widely and sufficiently. Needle and syringe exchange programmes are one of the most effective ways to reduce harm and prevent HIV transmission; they allow people to access social and psychological support to overcome their drug addiction, drug treatment and other health services, alongside clean needles. Here is an example from the UK National Institute for Health and Care Excellence (NICE), of good practice in the delivery of such programmes in the UK.
Furthermore, stigma and discrimination against people who use drugs needs to be tackled so they can access treatment and reduce the risk of being exposed to HIV. This would also lessen the chance of HIV transmission to other population groups through sex work and unsafe sex in general.
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