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Combination Approaches: Harm Reduction for Injecting Drug Users
I. Definition of Prevention Area
Drug use is a major factor in the spread of HIV infection in many settings. Sharing equipment used for injecting drugs transmits HIV, and drug use is linked with unsafe sexual activity that can increase HIV risk. Harm reduction programs focus on reducing the transmission of HIV associated with injecting drug use, while not necessarily trying to eliminate drug use itself. HIV prevention programs for injecting drug users (IDUs) may focus on decreasing needle use or needle sharing directly or by stabilizing the lives of IDUs.
II. Epidemiological Justification for the Prevention Area
The Reference Group to the United Nations on HIV and Injecting Drug Use estimates that 3 million people who inject drugs are HIV-positive (2008). While injecting drug use is of particular concern in South and Central Asia, Eastern Europe, and Russia, the practice is also growing in sub-Saharan Africa—particularly Kenya and Nigeria, which already face generalized HIV epidemics.
Sharing non-sterilized injecting equipment is one of the most efficient ways of transmitting HIV and promoting rapid spread of HIV within IDU populations. As reported by the International Harm Reduction Association in its 2008 report, in many countries, including China, India, Kenya, Myanmar, Nepal, Thailand, and Vietnam, HIV prevalence among IDUs is 50 percent or higher. Injecting drug use is associated with risky sexual behavior that may permit HIV transmission to cross into the non-IDU population. Evidence from numerous settings suggests that women injectors often exchange sex for material needs. Injection drug use is also associated with the transmission of other infectious diseases, such as hepatitis C.
Studies conducted over the past two decades confirm that harm reduction programs for IDUs consistently reduce HIV risk without increasing drug use. Medically assisted treatment (MAT) using methadone, buprenorphine, buprenorphine/naloxone (suboxone)/naltrexone or other medications/therapies and is associated with declines in HIV-related risk factors, such as injecting drug use and the number of sexual partners. The use of methadone and buprenorphine has been documented to prevent HIV transmission among IDUs. Needle and syringe programs (NSPs) are also associated with a decrease in self-reported risk behaviors among IDUs and with reduced rates of HIV transmission.
III. Core Programmatic Components
In July 2010, the President's Emergency Plan for AIDS Relief (PEPFAR) issued revised guidance on HIV prevention programming for IDUs. The guidance recognizes harm reduction as part of a comprehensive approach combining structural, biomedical, and behavioral interventions. PEPFAR recommends that programs select a combination of interventions and strategies from among the following, as their situation merits, carried out in a manner consistent with human rights obligations:
- Community-based outreach
- HIV counseling and testing (HCT)
- Antiretroviral therapy (ART) for IDUs living with HIV
- Prevention and treatment of sexually transmitted infections (STIs)
- Condom programs for IDUs and their sexual partners
- Targeted information, education, and communication (IEC) for IDUs and their sexual partners
- Vaccination, diagnosis, and treatment of viral hepatitis
- Prevention, diagnosis, and treatment of tuberculosis (TB)
PEPFAR encourages government agencies and civil society to develop the necessary legislation, policies, and regulations to facilitate implementation and scale-up of these evidence-based services.
In recent years, there has been a rapid increase in the proportion of IDUs who are women, especially in Asia and Eastern Europe. In China, researchers have documented a rapid increase in the number of women IDUs who share injection equipment. Special attention to the unique needs of female IDUs is thus warranted.
IV. Current Status of Implementation Experience
Many countries in Asia and Eastern Europe have interventions for IDUs to reduce the demand for drugs. Such interventions have had limited success in preventing harmful consequences of drug use, including hepatitis C and HIV. Evidence and data from multiple programs and research studies show that harm reduction is the most successful approach to HIV programming for IDUs.
Successful programs for IDU in under-resourced countries have been characterized by:
- A combination of behavioral, biomedical, social normative, and structural strategies and
harm-reduction approaches that target different audiences.
- An evidence-driven approach integrating program monitoring, evaluation, and operations
research designed to help the program adapt to new challenges and reach newly identified
- The involvement of affected communities in all aspects of the response to the epidemic.
- Effective linkages to government services, ensuring access to basic health care services and treatment.
- Flexible, responsive advocacy for supportive policies and an improved regulatory environment.
The new PEPFAR guidance calls for governments to reject punitive policies that drive IDUs underground and instead actively support IDU programming to build an enabling environment for prevention.
Structural Interventions to Reduce HIV Transmission among Injecting Drug Users
Des Jarlais, D. C. AIDS (2000), Vol. 14 Suppl. 1, pp. S41–6.
This review of the literature identifies what structural interventions are effective in reducing HIV transmission among IDUs. Structural interventions change the environment in which drug use and HIV risk behaviors occur by either making it easier for individuals to practice risk reduction or by making it harder for individuals to engage in risky behaviors. Despite methodological difficulties in evaluating them, structural interventions tend to have large effects due to the nature of their macro-level implementation. The most important structural intervention has been to provide legal access to sterile injection equipment, either through over-the-counter (OTC) pharmacy sales or SEPs. Studies from the United States and Australia find an association between SEPs and a reduction in HIV transmission among IDUs without increasing drug use in the general population. The author cautions that some structural interventions intended to reduce drug use—suppressing noninjecting drug use, restricting distribution and/or possession of needles and syringes, and jailing addicts—may inadvertently increase HIV among drug users. A science-based approach to HIV prevention is urged, particularly as it relates to drug use.
Comprehensive HIV Prevention for People Who Inject Drugs, Revised Guidance
The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). (2010).
On July 16, 2010, PEPFAR released revised guidance on comprehensive HIV prevention for people who inject drugs. The revised guidance provides support for a comprehensive package of prevention services that have been scientifically demonstrated to decrease HIV infection risk without increasing drug use, including the following three elements: (1) community-based outreach programs; (2) sterile needle and syringe programs (NSPs); and (3) drug dependence treatment, including medication-assisted treatment (MAT) with methadone, buprenorphine, and/or other effective medications as appropriate, based on the country context.
Optimal Provision of Needle and Syringe Programmes for Injecting Drug Users: A Systematic Review
Jones, L., Pickering, L., Sumnall, H., et al. International Journal of Drug Policy (2010), Vol. 21 No. 5, pp. 335–42.
This systematic review of studies looking at NSPs compares the efficacy of different types of NSPs, other harm reduction services that they offer, and how such programs are delivered. There were only 16 studies that met the inclusion criteria, including 11 on different types of NSPs, 3 on NSPs and additional harm reduction services, and 2 on the delivery of NSPs in combination with opiate substitution. The paper includes a useful table detailing the design and outcomes of each study. The authors conclude that there is insufficient information to draw firm conclusions about what type of NSP works best overall.
The Lancet Series: HIV in People Who Use Drugs
The Lancet. (2010).
This collection of articles represents a call to arms for greater efforts to tackle the issue of HIV among people who use drugs. Commentaries address the myths surrounding drug use and HIV, and the special burden borne by women. Papers cover the risk environment for injection drug users (IDUs), HIV prevention in this population, and treatment of comorbidities among drug users living with HIV. Not only does the series look at biomedical issues such as antiretroviral HIV treatment, opioid substitution, and NSPs, it also covers social issues that prevent effective HIV prevention among IDUs and proposes a human rights-based approach to people who use drugs.
HIV Prevention, Treatment, and Care Services for People Who Inject Drugs: A Systematic Review of Global, Regional, and National Coverage
Mathers, B. M., Degenhardt, L., Ali, H., et al. The Lancet (2010), Vol. 375 No. 9719, pp. 1014–28.
This seminal review of estimated national, regional, and global coverage of HIV services for IDUs examines the extent to which NSPs, opioid substitution therapy (OST), and antiretroviral therapy have been implemented. The review spells out the wide regional variations in access to harm reduction and HIV treatment services, and shows that despite the large number of countries with HIV prevention services, coverage of IDUs is too low to prevent HIV transmission in most countries. The authors explain the policy implications of their findings and call for similar reviews of other health problems affecting IDUs, such as tuberculosis and viral hepatitis.
HIV Prevention among Injecting Drug Users: Strengthening U.S. Support for Core Interventions
Needle, R. H., & Zhao, L. (2010).
This presentation starts with big-picture data on injecting drug use and IDUs living with HIV. Using data sourced from a review of official reports and a survey of country experts, the presenters found that only 1 in 10 IDUs in PEPFAR countries use NSP services, and that those that have access to these services do not receive a sufficient annual supply of needles. Antiretroviral therapy and MAT are also only available to a tiny minority of IDUs in PEPFAR countries. The presentation highlights the barriers to service implementation and the cost of scaling up services, concluding with recommendations for future service provision targets.
Global Epidemiology of Injecting Drug Use and HIV among People Who Inject Drugs: A Systematic Review
Mathers, B. M., Degenhardt, L., Phillips, B., et al. The Lancet (2008), Vol. 372 No. 9651, pp. 1733–45.
There are nearly 16 million IDUs worldwide (range of 11.0 to 21.2 million) and an estimated 3 million IDUs with HIV (range of 0.75 million to 6.6 million). HIV prevalence among IDUs varies considerably, with nine countries with prevalence rates over 40 percent and another five countries with prevalence between 20 and 40 percent. China, Russia, and the United States had the largest number of IDUs. These data reflect the need to invest in HIV prevention activities, such as syringe and needle exchange programs, OST, and care and treatment for those with HIV. Furthermore, developing capacity to research IDUs in countries will help better understand specific needs among them, and thus program more targeted solutions to reduce HIV transmission and other harms related to injecting drug use.
Women, Harm Reduction and HIV
Pinkham, S. & Malinowska-Sempruch, K. Reproductive Health Matters (2008), Vol. 16 No. 31, pp. 168–81.
These resources examine the unique issues that increase women’s risk of acquiring HIV through injecting drug use and impede their ability to seek support, treatment, and care. Female IDUs are more likely to be infected with HIV than their male counterparts because of both sexual and injection practices. Furthermore, commercial sex work and injecting drug use overlap in many countries, with IDUs more likely to work on the street and experience physical violence. Sexual health services for IDUs are rare. Female IDUs who are pregnant or mothers often lack proper antenatal care and treatment, and often suffer punitive actions from the medical and law enforcement establishments. Programs can address the issues unique to female IDUs by adopting policies that encourage women to seek drug treatment and harm reduction services; incorporating sexual and reproductive health and other women’s services into harm reduction programs; and establishing strong links between harm reduction, drug treatment, women’s shelters, and domestic violence and rape prevention services.
The Impact of Methadone or Buprenorphine Treatment and Ongoing Injection on Highly Active Antiretroviral Therapy (HAART) Adherence: Evidence from the MANIF2000 Cohort Study
Roux, P., Carrieri, M. P., Villes, V., et al. Addiction (2008), Vol. 103 No.11, pp. 1828–36.
Widespread NSPs and OST programs in France have resulted in dramatic decreases in HIV prevalence among IDUs. What is not known is whether take-home OST has a long-term impact on HAART adherence among IDUs, and therefore, improved clinical outcomes. This study assessed the relationship between OST use and HAART adherence among a cohort of IDUs living with HIV. Subjects who, despite imperfect records of abstinence from injecting during the follow-up period, reported maintaining a six-month period of noninjection in the context of OST, mirrored abstinent injecting drug use in HAART adherence. Length of time using OST without injecting was positively correlated with improved viral load. Despite a small number of patients, the authors conclude that ensuring widespread access to an adequate dose of OST that can be taken home can have a positive impact on sustained adherence to HAART.
Access to Syringes in Three Russian Cities: Implications for Syringe Distribution and Coverage
Sarang, A., Rhodes, T., & Platt, L. International Journal of Drug Policy (2008), Vol. 19 Suppl. 1, pp. S25-36.
Based on interviews with IDUs and data from a community survey, this study found that most respondents used pharmacies to obtain needles and syringes, with only a tiny minority using syringe exchange programs (SEPs). The latter were associated with other benefits such as access to health care services. However, pharmacies were favored, partly because of geographical proximity and low cost, but also because exchanging equipment entails carrying or storing used syringes, which was associated with the risk of police interference or discovery by other people. The authors question the added value of needle exchanges versus pharmacies in resource-poor settings and argue that their data supports the introduction of a distribution model based on established formal and informal networks.
Interventions to Address HIV in Prisons: HIV Care, Treatment and Support
Jürgens, R. (2007).
This technical paper states the case for implementing HIV prevention interventions in prisons. It reviews the existing evidence to ascertain whether prison-based HIV interventions are effective, avoid unintended negative consequences, are acceptable to the target group, have any additional benefits, and are feasible in diverse prison settings. It presents evidence from both the community and prisons to make recommendations for action at international, country, and local levels, in particular making OST, antiretroviral therapy, and HIV testing and counseling available in prisons. The report also highlights the counterproductive nature of mandatory HIV testing and segregation of people living with HIV.
A Review of the Efficacy and Effectiveness of Harm Reduction Strategies for Alcohol, Tobacco and Illicit Drugs
Ritter, A., & Cameron, J. Drug and Alcohol Review (2006), Vol. 25 No. 6, pp. 611–24.
This review of over 650 articles on harm reduction strategies found that most strategies concerned illicit drugs. The review found compelling evidence to show that NSPs and outreach are useful and cost-effective, but findings to support noninjecting routes of administration, supervised injecting facilities, and naloxone distribution are only beginning to emerge. The existing evidence on brief interventions, HIV testing, and education is not conclusive. The review also evaluates harm reduction as a policy approach and finds that despite difficulties interpreting data, the evidence supports harm reduction as a driver of policy rather than just the basis of individual interventions.
Do Needle Syringe Programs Reduce HIV infection Among Injecting Drug Users: A Comprehensive Review of the International Evidence
Wodak, A., & Cooney, A. Substance Use and Misuse (2006), Vol. 41 No. 6-7, pp. 777–813.
Using commonly accepted criteria for evaluation of public health interventions, this study reviews evidence from 45 studies to find strong evidence that NSPs are effective, safe, and cost-effective. The evidence in favor of NSPs as an HIV prevention intervention is overwhelming, but the availability of sterile needles and syringes from pharmacies is a common confounder in studies looking at NSP implementation and HIV prevention. Moreover, although the benefits of NSPs are proven, they are insufficient on their own to prevent HIV among IDUs. The authors make recommendations for future action and also provide a useful glossary of terms.
The Social Structural Production of HIV Risk among Injecting Drug Users
Rhodes, T., Singer, M., Bourgois, P., et al. Social Science and Medicine (2005), Vol. 61 No. 5, pp. 1026–44.
The authors of this literature review argue that HIV infection is a behavioral disease, one that is strongly influenced by its surrounding environment. To develop effective HIV prevention programs, we must understand how the environment affects the risk of HIV among IDUs. Social and structural factors that may increase HIV risk are numerous: population movement, neighborhood disadvantage, public injecting spaces, and the criminal justice system, among others. The authors posit that the future of HIV prevention among IDUs depends on the extent structural and environmental interventions are promoted.
Can HIV-1 Contaminated Syringes be Disinfected? Implications for Transmission among Injection Drug Users
Abdala, N., Gleghorn, A., Carney, J. M., et al. Journal of Acquired Immune Deficiency Syndromes (2001), Vol. 28 No. 5, pp. 487–94.
In the absence of support for NSPs in the United States, harm reduction programs encouraged IDUs to disinfect their syringes with bleach. Several population-based studies in the 1990s cast doubt on bleach’s effectiveness in decontaminating used syringes among IDUs. This study recreated real-life situations among IDUs in the United States, including common injection practices, using 2 mL syringes. Based on other studies indicating that IDUs did not always follow the strict bleaching protocol, the study used multiple rinsing permutations (water only, diluted bleach, full-strength bleach; rinsing one, two, or three times; storing syringes for up to 48 days at room temperature) to assess whether these practices could remove HIV from a used syringe. While even one rinse of water could reduce the presence of HIV, number of rinses and adding bleach to the rinsing procedure furthered the decreases in amount of HIV recovered.
Laws Prohibiting Over-the-Counter Syringe Sales to Injection Drug Users: Relations to Population Density, HIV Prevalence, and HIV Incidence
Friedman, S. R., Perlis, T., & Des Jarlais, D. C. American Journal of Public Health (2000), Vol. 91 No. 5, pp. 791–3.
Some states in the United States have antidrug policies that include restricting the sale of syringes only to those with a prescription. Some researchers argue that such restrictions increase the extent to which IDUs share syringes and perhaps other drug paraphernalia. This cross-sectional analysis compared HIV prevalence and incidence among IDUs in the 96 largest metropolitan areas in the United States based on whether syringes were available OTC. The average HIV prevalence among IDUs in areas allowing OTC sales of syringes was 7 percent, but 14 percent in those with anti-OTC laws, a statistically significant difference. The difference in estimated average HIV incidence among IDUs was even greater: 61 percent in anti-OTC areas versus 17 percent in the other areas. Furthermore, there was no difference in the percentage of IDUs in each area, indicating that anti-OTC policies may have no effect on drug use. While these results may be due to other factors, this study does support that an association exists between anti-OTC policies and increased HIV levels.
Opiate Substitution Treatment and HIV Transmission in People Who Inject Drugs: Systematic Review and Meta-analysis
MacArthur, G.J., Minozzi, S., Martin, N. et al. BMJ (October 2012), e-publication ahead of print.
This systematic literature review and meta-analysis found that opiate substitution treatment is associated with a 54 percent reduction in HIV risk for people who inject drugs (PWID). A second but weaker finding is that longer exposure to opiate substitution treatment may provide HIV prevention benefits for PWID. According to the authors, these findings are in line with the hypothesis that successful substitution treatment removes PWID from risky injection situations. These results come from the authors’ review of data from 12 published and 3 unpublished observational studies on opiate substitution treatment, specifically methadone maintenance. Their analysis was based on pooled data from nine of the studies, which together yielded 819 incident HIV infections over 23,608 person-years of follow-up. Despite the clear evidence of the benefits of opiate substitution treatment, the authors point out that only an estimated 6 to 12 percent of PWID worldwide are enrolled in this form of therapy. The authors argue that, given rising HIV incidence among PWID in many regions of the world, their findings support opiate substitution treatment for this key population. The authors conclude by urging support for interventions that combine proven prevention approaches for PWID, including opiate substitution therapy, needle and syringe exchange, and other forms of harm reduction programming.
Making Harm Reduction Work for Women: The Ukrainian Experience
Pinkham, S., & Shapoval, A. (2010).
The special needs of women in terms of harm reduction are well illustrated in this report, which describes the outcome of gender-responsive harm reduction programs in six Ukrainian cities. Each project was an enhancement to an existing harm reduction program. Several key themes ran through the projects, namely sexual and reproductive health, parenthood and family preservation, legal aid and social support, empowerment of women, and referrals and networks of providers. The programs achieved impressive results with limited funding, but the authors argue that a multi-sectoral approach will be needed to provide comprehensive and effective care for women IDUs. The authors give recommendations for future policy and services.
Human Rights and Drug Policy: Harm Reduction in Places of Detention
Human Rights Watch, Open Society Institute Public Health Project, & International Harm Reduction Association. (2009).
This briefing explains the relationship between injecting drug use and HIV transmission in the context of prisons, citing examples from Lithuania and South Africa to illustrate the vulnerability of prison populations to HIV. It describes the key requirements for interventions in prisons and highlights the importance of introducing harm reduction measures such as NSPs. Although some countries have introduced limited harm reduction programs in prisons, lack of political will, policies that favor zero tolerance over evidence-based harm reduction, and negative public attitudes toward drug users are significant obstacles to widespread introduction of programs targeting this vulnerable population.
Saved by the Nose: Bystander-Administered Intranasal Naloxone Hydrochloride for Opioid Overdose
Doe-Simkins, M., Walley, A. Y., Epstein, A., et al. American Journal of Public Health (2009), Vol. 99 No. 5, pp. 788–91.
This report describes an opioid overdose prevention program in which needle exchange clients received training from nonmedical needle exchange staff in the administration of intranasal naloxone hydrochloride and successfully intervened to reverse opioid overdoses. The report shows that, given the necessary support and regulation, overdose prevention programs do not require a direct encounter between the patient and a health care provider, and programs training nonmedical personnel to use naloxone are feasible in city settings. The article also provides responses to the typical legal and regulatory barriers to the implementation of such a program.
Estimated Drug Overdose Deaths Averted by North America's First Medically-Supervised Safer Injection Facility
Milloy, M.-J. S., Kerr, T., Tyndall, M., et al. PLoS One (2008), Vol. 3 No. 10, p. e3351.
This report describes the expansion of harm reduction services that came about with the opening of North America's first medically-supervised safer injection facility in Vancouver, Canada. The study used various statistical models to estimate the number of deaths averted among users of the facility versus the neighborhood in which it is situated. The authors found that, even using the most conservative published estimates of the neighborhood ratio of nonfatal to fatal overdoses, the safer injecting facility averted deaths due to overdose among its users. The data support the facility's positive public health impact.
Reducing HIV Infection among New Injecting Drug Users in the China-Vietnam Cross Border Project
Des Jarlais, D. C., Kling, R., Hammett, T. M., et al. Journal of Acquired Immune Deficiency Syndromes (2007), Vol. 21 Suppl. 8, pp. S109–14.
This project assessed whether large-scale HIV prevention programs among IDUs in developing and transitional countries could bring the HIV epidemic under control. A peer outreach model in five Vietnamese and four Chinese sites provided IDUs with information on reducing drug use and sexual risk behaviors. Safe injection equipment, sterile water for injection, condoms, and vouchers for these items were widely distributed. This project had the support of law enforcement, government leaders, and community members. Cross-sectional survey data on HIV prevalence and estimated incidence among new injectors mirrored the project’s implementation and scale-up—there was no change during start up, but there were sustained decreases in HIV rates once the project reached full coverage. HIV incidence and prevalence declined by about 75 percent at end line 36 months later. Such data are the first in developing and/or transitional countries, providing evidence that programs can indeed be implemented in such countries.
Assessing the Role of Syringe Dispensing Machines and Mobile Van Outlets in Reaching Hard-to-Reach and High-Risk Groups of Injecting Drug Users (IDUs): A Review
Islam, M. M., & Conigrave, K. M. Harm Reduction Journal (2007), Vol. 4, p. 14.
This review of studies on the use of needle and syringe dispensing machines and mobile vans by needle and syringe programs evaluates their effectiveness in reaching IDUs who are otherwise not easily reached. Typical hard-to-reach IDUs include those who are homeless, young, female, from an ethnic minority, prisoners, or new injectors. The review showed that mobile vans have gained more acceptance than dispensing machines, but also that the services complement each other. Dispensing machines offer complete anonymity at the expense of interaction with health staff, while mobile vans mitigate the lack of anonymity with greater convenience for clients and acceptability by local residents.
Assessing the Feasibility of Harm Reduction Services for MSM: The Late Night Breakfast Buffet Study
Rose, V. J., Raymond, H. F., Kellogg, T. A., et al. Harm Reduction Journal 2006, Vol. 3, p. 29.
One of the few studies specifically looking at harm reduction among men who have sex with men (MSM) and are also IDUs, this paper describes the Late Night Breakfast Buffet, a van-based harm reduction service providing needle exchange, oral HIV testing, urine based tests for sexually transmitted infections (STIs), and harm reduction information between 1:00 a.m. and 5:00 a.m. in three neighborhoods of San Francisco. High utilization of methamphetamine was identified in this population. Although only a pilot project, the service establishes such harm reduction interventions as feasible in reaching an otherwise disenfranchised, high-risk population.
Pointing the Way: Harm Reduction in Kyrgyz Republic
Wolfe, D. (2005).
Site visits and interviews with multiple stakeholders working in harm reduction in the Kyrgyz Republic formed the basis for this report documenting current best practices. While most former Soviet countries continued with the punitive Soviet model of treating IDUs, the Kyrgyz Republic adopted harm reduction on multiple levels. Best practices detailed include mobilizing stakeholders across various government offices, donor coordination, syringe and needle exchange programs, and harm reduction in prisons. While efforts were too new and on too small a scale to show changes in key macro-level indicators, project data suggest that risky injecting and risky sex practices have declined, as have overdoses. Furthermore, field experience shows how to work in small, tight-knit communities, involving family members, sex workers, and many populations that routinely are shunned and punished in the former Soviet countries.
Measuring the Impact of Needle Exchange Programs among Injecting Drug Users Through the National Behavioural Surveillance in Bangladesh
Jenkins, C., Rahman, H., Saidel, T., et al. AIDS Education and Prevention (2001), Vol. 13 No. 5, pp. 452–61.
This study interviewed 1,187 IDUs in Dhaka and Rajshahi, Bangladesh, at or near sites where drugs are obtained or used as part of a second round of national HIV behavioral surveillance. Participants in needle exchange programs in both locations were found to be less likely to share injecting equipment. Important differences were found in the demographics of IDUs and in injecting behavior between the two cities This study is likely to provide valuable ethnographic insight to program planners working in Bangladesh. Study data suggest the value of safe injection houses or a similarly stable, safe environment as a strategy to reduce harm associated with injecting among addicts with high levels of homelessness and mobility.
Controlling HIV Epidemics Among Injection Drug Users: Eight Years of Cross-Border HIV Prevention Interventions in Vietnam and China
Hammett, T.M., Des Jarlais, D.C., Kling, R., et al. PLOS ONE (August 2012), Volume 7 No. 8, p. e43141.
The Cross-Border HIV Prevention Project for IDUs in Southern China and Northern Vietnam, launched in 2002, provides peer education and distributes needles and syringes to people who inject drugs (PWID) in the South China-Vietnam border region, where injection drug use drives HIV transmission. The authors report on an eight-year study of the project, one of the longest studies of HIV prevention efforts in Asia among PWID. The study used 26 waves of serial cross-sectional surveys of PWID living near project sites in the region, as well as interviews and HIV testing, with the objective of determining change over time in HIV risk behaviors and in HIV incidence and prevalence. Analysis of the data revealed statistically significant decreases in self-reported drug-related risk behaviors (i.e., sharing drugs and injection equipment in different ways). Furthermore, HIV prevalence dropped sharply in provinces with Cross-Border Project interventions, and HIV incidence declined significantly through the 36- to 48-month period; some rebound in incidence occurred later, but again declined significantly through 96 months. While it is not possible to directly link these results to Cross-Border Project activities, the authors write that the consistency in the trends they uncovered across primary outcomes provides strong support for an intervention effect.
Partnering with Law Enforcement to Deliver Good Public Health: The Experience of the HIV/AIDS Asia Regional Program
Sharma, M. & Chatterjee, A. Harm Reduction Journal (July 2012), Vol. 9, p. 24.
In Southeast Asia, most governments use a punitive approach to controlling the illegal drug trade and provide few harm reduction services for people who inject drugs (PWID). According to the authors, the impact on public health has been largely negative, contributing to high regional prevalence of such blood-borne viral infections as HIV and hepatitis B and C. The authors describe the activities of the HIV/AIDS Asia Regional Program (HAARP), which works to prevent HIV transmission stemming from injection drug use and improve the legal and policy environment in four Southeast Asian countries and in southeast China. HAARP collaborates with ministries of health, national drug control agencies, and police to create an enabling environment for drug policies that respect human rights, build capacity among health and law enforcement agencies, and support effective harm reduction services. The authors detail how HAARP implemented a large-scale harm reduction program that conducted research, policy advocacy, and study visits and training for law enforcement agencies across several borders. Among HAARP’s accomplishments are a harm reduction training curriculum for law enforcement adaptable to different countries, and research on the harmful consequences of China’s system for tracking convicted drug users. HAARP country programs also increased the number of needle and syringe service sites in the region from 11 in 2008 to 82 in 2012.
Injecting Drug Use and HIV
Maher, L. & Walsh, N. Current Opinion in HIV and AIDS (July 2012), Vol. 7 No. 4, pp. 317-19.
This editorial discusses eight articles outlining important developments in the field of injecting drug use and HIV, including advances in HIV prevention science, combination prevention and treatment as prevention, syringe design, challenges to scale-up and coverage, criminalization of drug use, and co-morbidities with hepatitis and tuberculosis. The first article discusses recent science and the implications for combination prevention for people who use drugs (PWID) and stresses that existing interventions such as needle and syringe programs, opioid substitution therapy, voluntary counseling and testing, and linkage to care are still some of the most cost-effective and efficient interventions for resource-limited settings. The second article examines some of the barriers to participation in HIV biomedical prevention trials and adherence issues among women who use drugs. Several of the other articles discuss such issues as ethnic and racial disparities within the HIV epidemic and their implications for prevention among PWID; the benefits of scaling up combination prevention interventions and treatment for PWID; the role of institutional and structural barriers, including criminalization of drug use; and the importance of treating co-morbidities endemic to PWID. According to the authors, all of the articles highlight the need for an increased evidence base of effective interventions for PWID, increased access to both prevention and care for PWID, and strategies to decrease barriers to accessing services, such as criminalization of PWID.
Barriers to HIV Treatment Among People Who Use Injection Drugs: Implications for 'Treatment as Prevention'
Milloy, M.J., Montaner, J., & Wood, E. Current Opinion in HIV and AIDS (May 2012), e-publication ahead of print.
According to the authors of this article, treatment as prevention strategies for people who inject drugs (PWID) will only be successful when structural issues, including punitive addiction treatment policies and criminalization of injection drug use, are consistently and effectively addressed. The authors find that PWID continue to experience low rates of HIV testing and of access and adherence to highly active antiretroviral treatment (HAART), as well as higher rates of HIV-related morbidity and mortality. They write that HIV treatment success among PWID depends on the ability to not only identify and address individual-level factors but also structural factors inhibiting access and adherence to treatment. The authors cite criminalization and incarceration of PWID as some of the major social and structural factors interrupting or leading to discontinuation of ART. According to the authors, lack of social support and lack of privacy for taking medications have also been identified as reasons for stopping ART use. The authors also point out that, in Asia and the former Soviet Union, state-run compulsory detention centers may inhibit treatment adherence because detainees lack appropriate evidence-based care and are often subjected to forced detoxification and indentured labor. The authors call for de-emphasizing the criminal justice-based approach to illicit drug use, particularly incarceration. Instead, they recommend a more comprehensive approach that offers substitution therapies, directly observed treatment, and other evidence-based addiction treatment services.
HIV in Prisons: Situation and Needs Assessment Toolkit
Weilandt, C., & Greifinger, R. (2010).
Aimed at national governments, particularly those of low- and middle-income countries, this toolkit first explains HIV in the prison context. It then provides the necessary tools to conduct the situation and needs assessments required before HIV intervention programs can be implemented. Although it focuses on HIV and tuberculosis-related HIV, it is also relevant to STIs and hepatitis. The toolkit recommends the establishment of a multidisciplinary steering committee and lays out a stepwise assessment process. Annexes include templates for consent forms and questionnaires, checklists, and information about sampling methodology.
Good Practice Guide: HIV and Drug Use: Community Responses to Injecting Drug Use and HIV
International HIV/AIDS Alliance. (2010).
This comprehensive guide to HIV and drug use, written in clear, accessible language, aims to support community-based harm reduction and HIV programs, with a focus on developing and transitional countries. It thoroughly explains the issues of drug use, HIV, and health, and covers programs for special populations—women, children and young people, and prisoners—in a separate section. It spells out approaches to harm reduction, including community mobilization and gender-sensitive programming, and highlights the importance of involving all stakeholders, including people who use drugs, in programming. The guide describes in detail the HIV/AIDS Alliance good practice standards and spells out the key characteristics of effective programs.
Overdose Prevention and Response: A Guide for People Who Use Drugs and Harm Reduction Staff in Eastern Europe and Central Asia
Curtis, M., & Guterman, L. (2009).
Although this guide was produced with harm reduction staff and people who use drugs in Eastern Europe and Central Asia in mind, the information it contains is useful worldwide. The guide explains the basics of overdose, such as what happens to the body during overdose and the duration, potency, and overdose risk of different drugs. It describes the risk factors associated with overdose prevention and explains how to recognize an overdose. There is a section on responding step-by-step to an overdose, including a guide to rescue breathing and instructions for administering naloxone in the case of opioid overdose. A chapter for trainers on how to use the information provided completes the guide.
Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users
World Health Organization (WHO), U.N. Office on Drugs and Crime (UNODC), & Joint U.N. Programme on HIV/AIDS (UNAIDS). (2009).
This guide explains the rationale for including nine different evidence-based interventions in a comprehensive package of HIV prevention, treatment, and care for IDUs. Recommended interventions include harm reduction measures, HIV testing, counseling and treatment, and prevention and treatment of STIs, viral hepatitis, and tuberculosis. Frameworks are given for each recommended intervention. A checklist offers guided assessment of the availability, coverage, and quality of each intervention.
Guide to Starting and Managing Needle and Syringe Programmes
WHO, UNAIDS, & UNODC. (2007).
This guide is designed to assist in expanding the response to HIV among IDUs. Many more NSPs will need to be established to meet the harm reduction needs of the growing IDU population. Sections I and II of this guide describe how to foster this process. Sections III and IV discuss how existing NSPs can expand the services that they offer and greatly increase their coverage. Scale-up of such programs must include establishing more NSPs in prisons and detention centers. Section V presents the particular needs of NSPs in such “closed settings.” The end of the guide provides a list of useful websites, publications, and networks.
Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs: A Treatment Improvement Protocol TIP 43
Batki, S. L., Kauffman, J. F., Marion, I., et al. (2005, reprinted 2006).
This highly detailed but easy to use document comprehensively explains the best practice guidelines for MAT of opioid addiction. There are chapters on the pharmacology and clinical pharmacotherapy of medication, the screening and assessment of potential candidates for treatment, and how to match patients with appropriate treatment options. The practicalities of providing MAT, from phases of treatment to maximizing patient retention, are covered. There are specific guidelines on the medical problems and co-occurring disorders typically seen in opioid addicted patients, as well as chapters on treating patients with multiple substance use and treating opioid addiction during pregnancy. The guide also covers administrative considerations such as staffing and program evaluation.
Advocacy Guide: HIV/AIDS Prevention among Injecting Drug Users
WHO, UNAIDS, & UNODC. (2004).
This guide provides a systematic approach to advocacy for HIV prevention and care among IDUs that can be replicated and adapted to various cultural, economic, and political settings. General principles of advocacy for HIV/AIDS prevention and care for IDUs are first presented. A step-by-step process is provided to establish advocacy groups with specific goals, undertake a situation analysis, develop a strategy, and implement the strategy. It also contains descriptions of many tools and methods for achieving advocacy goals and examples of their use in various country settings. Frequently used arguments related to HIV/AIDS prevention among IDUs are also included. Most methods in the guide can be used, after adaptation, at community, district, and national levels.
Training Guide for HIV Prevention Outreach to Injecting Drug Users: Workshop Manual
This training package is for workshops orienting and training public health policymakers, program developers, program managers, implementers, and field workers on IDU outreach for preventing HIV transmission. The training package has four workshop modules. Orientation to Outreach among IDUs provides evidence for the effectiveness of outreach programs and assists decision makers in introducing and developing such programs. Developing Outreach Programs for HIV Prevention among IDUs provides assistance to individuals interested or involved in developing outreach programs. Managing Outreach Programs among IDUs is for those who have never managed an outreach program, but can also be used as additional training for current managers and outreach field supervisors. Core Skills in Outreach among IDUs is designed for initial training of outreach workers or as a resource for ongoing training and revision among experienced outreach workers.
Manual for Reducing Drug Related Harm in Asia
Centre for Harm Reduction, Macfarlane Burnet Centre for Medical Research, & Asian Harm Reduction Network. (2003).
This comprehensive manual grew out of the combined efforts of people in Asia to stop HIV. The first section presents background information on drug use and HIV vulnerability, the rationale for harm reduction, and balancing and integrating the approaches of supply, demand, and harm reduction. Briefing papers on critical issues, such as mapping drug use in Asia and care and support of IDUs with HIV, are included for use as advocacy tools in the region. The second section contains nine chapters on program design, implementation, and maintenance, including rapid assessments, voluntary counseling and testing, and addressing the needs of specific groups. The third section contains appendices with information on hepatitis A, B, and C; HIV; illicit drugs and their characteristics; and STIs.
Injecting Risk Questionnaire
Center for Research on Drugs and Health Behaviour, London School of Hygiene & Tropical Medicine. (1982).
This questionnaire measures the extent and nature of sharing needles, syringes, and other injecting equipment to assess levels of injecting risk behavior. It identifies different sharing practices and can be used for different types of IDUs. It can be used to assess need and target interventions. In the context of an appropriate research design, it can be used to help assess the impact of prevention services such as needle and syringe distribution schemes, publicity campaigns, peer education, and drug treatment programs. The questionnaire covers the direct sharing of needles and syringes, as well as sharing ancillary equipment (indirect sharing). It takes about five minutes to complete.
The Global HIV Epidemics among People Who Inject Drugs
Dutta, A., Wirtz, A., Stanciole, A., et al. 2013. The Global Epidemics among People Who Inject Drugs. Washington, DC: World Bank.
Interventions targeting people who inject drugs (PWID) are not at sufficient levels to adequately reduce HIV transmission and acquisition rates, and without addressing the needs of this group overall success in countries will be challenging. The objectives of the study were to: 1) provide the economic evidence necessary to help advocate for increased services for PWID; 2) disseminate the results of the study to influence policy makers in making changes to their current HIV response to PWID; and 3) create a knowledge base for continual advocacy. Four key interventions for PWID were focused on in the analysis. These are needle and syringe programs, medically assisted therapy, HIV counseling and testing, and antiretroviral therapy (ART). Their level of effectiveness was determined by a review of the literature and used in four different modeling exercises depicting epidemiological data from Kenya, Ukraine, Pakistan, and Thailand. Each model explored how the expansion of coverage at the four intervention areas for PWID from 2012-15 would affect their HIV incidence rates and costs. The Goals mathematical model was utilized to measure no change in coverage, increase in coverage as is currently planned in national strategies, and increased scale-up. It was found across the four countries that reductions in HIV incidence were achieved when the four intervention areas were scaled up to achievable levels compared to the status quo scenario. It was also found that when a combination of the four intervention areas was scaled up, it was more effective and cost-effective compared to scaling up ART services alone. The findings indicate a need to drastically change the course of current HIV interventions targeting PWID.
The Global State of Harm Reduction 2012: Towards an Integrated Response
Harm Reduction International (July 2012).
One in three HIV infections outside sub-Saharan Africa is caused by unsafe injecting practices, which fuel HIV and other blood-borne epidemics in many regions. This biennial report, the third in a series published by Harm Reduction International, tracks developments worldwide in adoption of harm reduction policies and program implementation since 2010. The report also explores critical issues for building a comprehensive harm reduction response, such as harm reduction programs designed for women, access to programs for young people, drug use by men who have sex with men, and global progress in decriminalizing drug use. This year’s report paints a bleak picture of current harm reduction activity internationally. About half of the 158 countries included in the report have no programming at all to prevent HIV transmission through injection drug use; even in countries that have programming, coverage is poor, and donor support is declining. For example, in Russia the number of needle exchange programs has dropped from 70 in 2010 to only 6 in 2012. According to the report, scale-downs of this kind are occurring worldwide, a trend made worse by insufficient government commitment to harm reduction and to the unwillingness of bilateral and multilateral donors to maintain funding levels for harm reduction. On the positive side, harm reduction networks continue to make important contributions, including advocacy and research, and civil society has become increasingly engaged in mobilizing international support for harm reduction.
Asian Harm Reduction Network Library
Asian Harm Reduction Network (AHRN). (2010).
The AHRN's searchable online library offers registered users access to thousands of documents related to injecting drug use, with a focus on Asia. HIV is one of six main topics in the collection. Free subscription to an electronic newsletter is available and back issues may be downloaded or read online.
View AHRN Website
The Harm Reduction Coalition
The Harm Reduction Coalition. (2010)
The Harm Reduction Coalition is a national U.S. advocacy and capacity-building organization that promotes the health and dignity of individuals and communities affected by drug use. It advances policies and programs that help people overcome the adverse effects of drug use, including overdose, HIV, hepatitis C, addiction, and incarceration. In addition to training materials, calendars, and community resources, the website provides links to local services as well as ways that people can get involved.
View Harm Reduction Coalition Website
Open Society Institute: Harm Reduction and Drug Use
Open Society Institute (OSI). (2010).
One of the components of the OSI's Public Health program is harm reduction and drug use. This website contains OSI's resources and information on their work, including publications, articles, and multimedia on harm reduction and drug use. Events and resource links are also available.
People Who Use Injecting Drugs—Technical Policies of the UNAIDS Programme
A critical resource for policy development, this website brings together technical guidance, position papers, and policy briefs from UNAIDS. The technical guide lays out targets for access to HIV prevention, treatment, and care for IDUs. There are policy briefs on antiretroviral therapy and on the reduction of HIV transmission through drug dependence treatment, outreach, and NSPs. Position papers outlining the U.N. system's policy on HIV prevention among IDUs and a statement on HIV prevention and care strategies for IDUs round out the collection.
Harm Reduction Developments 2008: Countries with Injection-Driven HIV Epidemics
In 2007, IDUs comprised the largest share of total HIV cases in at least 20 nations in Asia and the former Soviet Union. This report provides an overview of harm reduction efforts in Central and Eastern Europe, the former Soviet Union, and five Asian countries. Examples of effective programs being implemented include syringe and needle exchange programs, advocacy, OST, harm reduction work in prisons, and programs with commercial sex workers, among others. Data presented include IDUs as a percentage of HIV cases, OST availability, and estimates of IDUs reached by HIV prevention services in these countries. Despite advances in harm reduction, much work remains. Issues identified as needing increased investigation and action in the future include women and harm reduction, sexual health and harm reduction, African injecting drug use epidemics, and evidence-based and humane drug treatment.
View Report (PDF, 1.35 MB)
"Nothing About Us Without Us": Greater, Meaningful Involvement of People Who Use Illegal Drugs: A Public Health, Ethical, and Human Rights Imperative
Canadian HIV/AIDS Legal Network, International HIV/AIDS Alliance, & OSI. (2008).
People who use illegal drugs have demonstrated that they can organize themselves and make valuable contributions to the community, including expanding the reach and effectiveness of HIV prevention and harm reduction services by making contact with those at greatest risk, providing much-needed care and support, and advocating for their rights and the recognition of their dignity. This report documents the public health and human rights rationales for including people who use drugs in developing HIV harm reduction programs. Recommendations on how to increase their involvement include addressing systemic barriers to allow a greater involvement of people who use drugs; supporting organizations of people who use drugs; involving people who use drugs in consultations, decision-making, or policymaking bodies, advisory structures, and community-based organizations; and providing international leadership on greater involvement.
View Report (PDF, 870 KB)
High Coverage Sites: HIV Prevention Among Injecting Drug Users in Transitional and Developing Countries: Case Studies
Burrows, D. (2006).
Part of the UNAIDS Best Practice Collection, this document contains seven case studies from countries in the former Soviet Union, Asia, and Latin America. These sites were selected because over half of IDUs have been reached by at least one HIV prevention program, hence the term high coverage. Each case study includes an overview of the country's drug use and epidemiology, services, and state of coverage. The last chapter synthesizes the lessons learned, identifying common features among them as well as challenges for comprehensive HIV-related programs. The report's most significant finding is that high-level coverage can indeed be attained by programs addressing HIV among IDUs in developing and transitional countries.
View Report (PDF, 1.57 MB)
HIV/AIDS Prevention and Care for Female Injecting Drug Users
This four-page brief highlights why female IDUs are more vulnerable than their male counterparts, including infected injections (women IDUs commonly inject after their male partner has), high-risk sex, stigma over behavior that contradicts expectations of women as nurturers, and physical vulnerabilities. Women who are even more vulnerable are commercial sex workers, women in prison, and pregnant females. Many existing services do not reach female IDUs because the services cannot meet their specific needs. To better reach female IDUs, comprehensive gender-sensitive services are recommended, including HIV counseling and testing, treatment for STIs, antiretroviral therapy for prevention of mother-to-child transmission, condoms, sterile needles and syringes, and gender-sensitive drug dependence treatment.
View Report (PDF, 95 KB)
Center for AIDS Prevention Studies Prevention Toolkit
University of California, San Francisco. (2006).
This content-rich website houses a wealth of HIV prevention resources, including over 60 referenced fact sheets that summarize important HIV prevention topics in a readable two-page format. There are detailed descriptions of model programs, both ongoing and completed, and interventions with full curricula available for download. Survey instruments that have been tested by the Center for AIDS Prevention and are adaptable to local settings are also available, as are evaluation manuals and a selection of resources guides. All content is also available in Spanish.
Policy and Programming Guide for HIV/AIDS Prevention and Care among Injecting Drug Users
This guide distills the principles of policies and programs that have worked well in responding to the HIV epidemic among IDUs. The guide is meant to be used by those developing such policies and programs throughout the world in conjunction with other WHO guides (see Guide to Starting and Managing Needle and Syringe Programmes and Advocacy Guide: HIV/AIDS Prevention among Injecting Drug Users). This guide shows how the strategies for each part of a comprehensive response are built and fit together.
View Report (PDF, 848 KB)
Drug Abuse and HIV/AIDS: Lessons Learned: Case Studies Booklet, Central and Eastern Europe and the Central Asian States
UNAIDS & UNODC. (2001).
Profound social and economic change in Eastern Europe and Central Asia has created conditions that make the countries in these regions particularly vulnerable to drug use and the spread of HIV. This booklet, aimed largely at policymakers and practitioners, presents an overview of lessons learned and challenges for the future. Examples from 11 countries (Belarus, Bulgaria, the Czech Republic, Hungary, Kazakhstan, Lithuania, Poland, the Russian Federation, Slovakia, Slovenia, and Ukraine) illustrate how drug abuse and HIV prevention strategies and interventions have been introduced into specific national and local contexts, and the responses to a number of important challenges. The case studies are grouped according to the focus of the project, as follows: fieldwork, political mobilization and strategy development, and training and networking. This collection shows the different adaptations that take place in response to local concerns, and also provides an up-to-date picture of the challenges commonly confronted in developing HIV prevention strategies among IDUs.
View Report (PDF, 958 KB)
The Asian Harm Reduction Network: Supporting Responses to HIV and Injecting Drug Use in Asia
This report presents the epidemiology of HIV in Asia and the genesis of the ARHN in response to evidence that IDUs represent a growing proportion of the HIV epidemic. ARHN focuses on supporting existing programs through strengthening existing ties and providing support for new responses through information dissemination, training, advocacy, and networking. AHRN has demonstrated that harm reduction is both possible and worth pursuing in Asia, sharing information through Listservs, reports, research repositories, and other means. The organization details lessons learned in establishing such a network in the last section of the report.
View Report (PDF, 414 KB)
Injecting Drug Use and Prisons Publications
This section of the WHO website houses a wealth of publications pertaining to injecting drug use and prisons. The site is divided into three sections. The first comprises documents on injection drug use in general; the second covers injection drug use in the prison context; and the third provides access to information produced by the WHO's regional offices. Many documents cited as essential reading in Appendix 1 of The U.S. President's Emergency Plan for AIDS Relief: Comprehensive HIV Prevention for People Who Inject Drugs, Revised Guidance (2010) may be found here.
International Harm Reduction Association
International Harm Reduction Association (IHRA). (2010).
The website of this important global advocacy organization houses the Global State of Harm Reduction 2010 report, detailing major developments and presented region-by-region. A two-page summary, What is harm reduction?, is available to download in 11 languages, and there is a comprehensive library of reports, briefings, and presentations on harm reduction. There are details of the IHRA's upcoming annual international conference, and the conference archive has materials and program details from the event in previous years.
View International Harm Reduction Association Website
Related Prevention Knowledge Base Interventions
Related AIDSTAR-One Case Studies
- USAID | Project SEARCH Fact Sheet: Needle and Syringe Programs (PDF, 3.63 MB)
- PEPFAR Guidance on Comprehensive HIV Prevention for People Who Inject Drugs
- UNAIDS Policy Forum on HIV, Human Rights, and People Who Inject Drugs
- Health Policy Project: Policy Analysis and Advocacy Decision Model for Services for People Who Inject Drugs (PDF, 2.56 MB)
- PWID Decision Model: Health Policy Project, Russian Translation (PDF, 2.68 MB)