Blood transfer, through the sharing of drug taking equipment, carries a high risk of HIV transmission. Around 30% 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 In Russia, the country with the greatest HIV burden among PWID, 57% of new HIV infections in 2013 were among this group.2 Other forms of drug use carry a risk of HIV transmission, but people who inject drugs (PWID) have the highest risk.
It is estimated that there are 12.2 million PWID worldwide, and around 1.65 million (13.5%) of this population are thought to be living with HIV. Four countries account for 63% of all people who inject drugs - China, Pakistan, Russia and the United States of America (USA) - reflecting the seriousness of the HIV epidemic for PWID in these countries. HIV prevalence among PWID is highest in South-West Asia (29.3%) and Eastern and South-Eastern Europe (22.8%).3
The 2011 Political Declaration on HIV and AIDS called for a 50% reduction in HIV transmission among PWID by 2015. Despite new diagnoses among this group declining by 10% between 2010 (110,000) and 2013 (98,000), it is highly unlikely that the 2015 target will be met.3
Why are people who inject drugs at risk of HIV transmission?
If a needle has been used by an HIV-positive person, infected blood in the needle can be injected into the next person who uses that needle. Between 5% and 10% of new HIV infections worldwide result from sharing used needles, jumping to 80% in Eastern Europe and Central Asia.4 5 Injecting drug users are also more likely to test for HIV late, increasing the chance of onwards HIV transmission.
However, sterile syringes are not always readily available, especially in countries with no/low roll-out of needle and syringe 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.6
Drug paraphernalia laws in some countries make it an offence to distribute or possess syringes for non-medical purposes, with people arrested for carrying them. This forces people to avoid carrying new needles, and use shared ones instead.7 8
"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." 9
Injecting 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. In Central Asia, Afghanistan and Mongolia, HIV prevalence among female sex workers who also inject drugs is 20 times higher than sex workers who don't inject drugs.10
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.11 The combination of these two effects led to HIV outbreaks among PWID, in places such as Greece and Bulgaria in 2011.12
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.13 In 2013, global HIV prevalence among women who inject drugs was 13%, compared to 9% among men who inject drugs.1
HIV prevention for people who inject drugs
Legalising and enforcing harm reduction methods, engaging PWID in the HIV response, and investing funding towards this population, are essential to implementing effective HIV prevention services.
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.14
Access to mental health services, sexual health check-ups and condoms are also necessary. Alongside these, harm reduction measures are needed such as needle and syringe programmes (NSPs), and opioid substitution therapy (OST). Efforts need to focus on prevention rather than simply awareness.15
Harm reduction programmes
Harm reduction programmes include needle and syringe programmes (NSPs) and opioid substitution therapy (OST).
These are effective in preventing HIV because they provide clean needles to drug users, and offer substitution medicines like methadone as an alternative to injecting drugs. Despite their resounding success in various settings worldwide, of the 158 countries that report PWID, only 90 have NSPs, and 80 provide OST.16 These programmes need to be scaled up everywhere in order to have a preventative effect for PWID and the wider population.
Here are some examples of successful harm reduction approaches for PWID:
- Kazakhstan has invested in needle and syringe programmes since 1997, resulting in a low HIV prevalence among PWID. This has continued to drop year on year, from 3.8% in 2012, to 2.8% in 2013. This is considerably impressive given the huge scale of the HIV epidemic among this population in the rest of Eastern Europe and Central Asia.
- The Tanzanian government has responded to high HIV prevalence among PWID by rolling out NSPs and OST. As a result, 84% of drug users used sterile equipment the last time they injected in 2013.17 Engaging with this population has allowed service providers (such as 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.18
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 1,000 times less fluid, 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 sparse and they need to be better supplied and rolled out among NSPs and pharmacies.19
Pre-exposure prophylaxis (PrEP) is a course of antiretroviral drugs (ARVs) taken before possible exposure to HIV, to prevent an infection from establishing in the body. In 2015, the World Health Organisation (WHO) recommended the use of PrEP for PWID, among other people at substantial risk of HIV.20
However, it is important that other forms of combination prevention are offered alongside PrEP, such as needle and syringe programmes and opioid substitution therapy, as these are the most effective ways of preventing HIV infection from injecting drugs.
Barriers to HIV prevention for people who inject drugs
The illegal nature of injecting drugs can 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.21 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.
Injecting drugs for purposes not prescribed by a doctor is illegal worldwide. The criminalisation of drug use and possession can hinder attempts to engage people who use drugs with available HIV services.
Decriminalisation would be a more supportive approach to this affected population, whereby they would not be forced underground to conceal their habit and to escape arrest, but rather engage in the HIV response and be active in protecting their own health.1
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.21 It is thought that 56% to 90% of drug users are imprisoned at some point in their life.22
People who inject drugs often find themselves on the wrong side of the law and in confrontation with the police, so 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.21
Harm reduction initiatives have been proven to help prevent HIV transmission among people who inject drugs, and yet only 91 out of 158 countries that report a presence of PWID permit the initiatives by law.16
The continuous creation of new drugs, with new ways to take them creates a never-ending cycle of HIV exposure opportunities. 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 encourages socialising and needs more 'hits' per day, leading to higher numbers of people sharing needles.23
The use of image and performance enhancing drugs (IPEDs) is rising rapidly, especially in more developed nations such as the UK.24 IPEDs are used to change a person’s image, and increase their level of performance. A 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.25 24 26
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 vaporising smoke 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 transmission.27
Barriers faced by young people who inject drugs
Although data for people who inject drugs is available, it is unknown how many young people inject drugs, or what the HIV prevalence among this group is. One report has suggested that 3% of young people who inject drugs are living with HIV.5
Many drug users start injecting when they are very young, with high proportions of teenage drug users in Eastern Europe and Asia especially. Young people are also likely to show more high-risk behaviour such as sharing needles or getting needles from unofficial places.28
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 OST may even deter young people because they require registration, parental consent or impose age restrictions.28 29
Funding HIV prevention for people who inject drugs
Funding low-cost harm reduction initiatives such as NSPs and OST is a much more cost-effective way of tackling HIV among PWID than having to pay for antiretroviral treatment for the rest of a person's life.1
Despite this, the vast majority of funding for harm reduction programmes comes from international sources rather than domestic governments. This makes it difficult to scale up the programmes as a country's epidemic adapts and changes, or to ensure its sustainability.
The majority of countries that have a large HIV prevalence among their drug user population are middle-income countries. International HIV funding for these countries is reducing in order to encourage more domestic sourcing, but the extra resources are not being made available by national governments.
Often, data on spending for PWID is not reported, or if it is, the avenues of spending are not spelt out meaning the funds could be going to drug detention centres rather than HIV prevention programmes.1
Antiretroviral treatment for people who inject drugs
One systematic review found that less than 4% of people who inject drugs who are living with HIV are on antiretroviral treatment (ART). The difference in treatment access within Europe is striking. In Western Europe, 89% of HIV-positive people who inject drugs are on ART. In Eastern Europe this figure is less than 1%.30
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 the risk of onwards HIV transmission.
Many governments favour policies that require absolute abstinence from illegal drug use before ART is provided.31 32 This deters drug users from seeking ART if they are forced to abstain from their drug addiction.
One study found that people who inject drugs while on antiretroviral treatment have lower achievement of viral suppression of HIV (56% to 58%) than those who do not inject (89%). Supporting people to adhere to their treatment (taking ARVs at the same time every day at least 95% of the time) among PWID is an essential part of ensuring treatment is successful.33
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.14 Better monitoring of this key affected population would also help inform effective HIV prevention responses tailored at the group, particularly young people who inject drugs.
Harm reduction measures including needle and syringe programmes and opioid substitution therapy should be implemented more widely and scaled up where they do exist. Needle and syringe 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.
Furthermore, stigma and discrimination against people who use drugs needs to be tackled so they can access treatment freely without the fear of stigma, 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 unprotected sex in general.
The war on drugs and criminalisation of PWID is pushing them away from services that could improve their health and that of the public. Countries need to reconsider any punitive laws and measures, such as detention centres and drug-registers, that are very prominent barriers to addressing HIV among people who inject drugs.
Photo credit: ©iStock.com/Burlingham. Photos are used for illustrative purposes. They do not imply any health status or behaviour on the part of the people in the photo.
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