HIV Prevention Knowledge Base
Combination Approaches: Harm Reduction for Injecting Drug Users
Making Harm Reduction Work for Women: The Ukrainian Experience
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
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
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
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
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
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
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
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
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
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
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
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'
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.