Immediate Action Using Multiple Approaches Needed To Slow Spread Of HIV Among Injection Drug Users
Sept. 15, 2006 - WASHINGTON -- Countries where HIV/AIDS rates are escalating because of injection drug use can and should act immediately to curb the spread of infection, says a new report from the Institute of Medicine. Evidence shows that a number of strategies -- including drug treatment, access to clean needles and syringes, and outreach to drug users -- are effective at decreasing risky drug-related behavior when used in a multicomponent approach and should be implemented where feasible. But each affected nation will have to determine the best combination of interventions for its economic, cultural, and social circumstances, the report says.
Although sub-Saharan Africa remains the area hardest hit by AIDS, this report focuses on Eastern European countries, former Soviet republics, and several parts of Asia, where HIV infection rates have increased by as much as 20 times over two decades as a result of injection drug use. Injection drug users spread HIV not only by sharing contaminated paraphernalia, but also by passing the virus to their sex partners and to newborns through mother-to-child transmission, the report notes.
“In nations where injection drugs account for a large proportion of HIV infections, national efforts must address both drug use and HIV transmission,” said Hugh H. Tilson, professor of public health leadership, epidemiology, and health policy, School of Public Health, University of North Carolina, Chapel Hill, and chair of the committee that wrote the report. “This is an urgent public health challenge that remains largely unmet. Several approaches to reducing risky injection drug behaviors can work, and affected nations cannot afford to wait to act.”
These countries’ multifaceted strategies should include certain medications to treat opiate addiction, as well as needle and syringe exchange wherever feasible, the report says. Studies provide evidence that treatment with methadone and buprenorphine -- drugs that prevent narcotic withdrawal symptoms and reduce cravings -- helps decrease individuals’ chances of contracting HIV, the committee found. And a large number of studies and reviews show that comprehensive HIV prevention programs which include needle and syringe exchange are associated with a reduction in behaviors that can lead to infection, such as needle sharing and frequent drug use. Counseling, education and outreach initiatives, and psychological interventions offer some benefits so they also should be used where feasible, the report says.
Although these interventions have been shown to reduce risky drug-related behaviors, there is less evidence of their ability to decrease risky sexual practices. Moreover, most studies have looked only at the interventions’ ability to curb risky behaviors and have not examined whether this translates into an actual reduction in HIV incidence, the report notes. Several studies show that continuous treatment with methadone and buprenorphine is associated with protection against HIV infection. But assessments of programs that include needle and syringe exchange have focused primarily on their impact on risk behaviors rather than on infection rates. There is limited evidence on the impact of outreach and educational efforts on HIV incidence.
“It is logical that reducing exposure to contaminated injection equipment and getting users to decrease or discontinue injection drug use would lead to lower incidence of HIV infection, but we simply lack sufficient studies that have gathered data on this,” Tilson said.
The implementation of multifaceted prevention programs in affected nations would provide an opportunity to assess the impact of needle and syringe exchange, outreach, and other individual program components on HIV incidence, the committee said. Studies during the implementation process would also help identify the most cost-effective interventions for countries with fewer resources. These economic studies are needed because some interventions may require significant amounts of funds, staff, and other resources, and most studies examining their impact have been conducted in the United States and other resource-rich countries.
In the meantime, however, countries that are able should immediately begin implementing treatment with methadone or buprenorphine, programs that include access to sterile needles and syringes, and outreach initiatives while these studies are being conducted, the committee said.
The study was sponsored by the United Nations Programme on HIV/AIDS and the Bill & Melinda Gates Foundation. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies. A committee roster follows.
Pre-publication copies of PREVENTING HIV AMONG INJECTING DRUG USERS IN HIGH RISK COUNTRIES: AN ASSESSMENT OF THE EVIDENCE are available from the National Academies Press; tel. 202-334-3313 or 1-800-624-6242 or on the Internet at HTTP://WWW.NAP.EDU. Reporters may obtain a copy from the Office of News and Public Information (contacts listed).
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INSTITUTE OF MEDICINE
Board on Global Health
COMMITTEE ON PREVENTION OF HIV INFECTION AMONG
INJECTING DRUG USERS IN HIGH RISK COUNTRIES
HUGH TILSON, M.D, DR.P.H. (CHAIR)
Clinical Professor of Public Health Leadership and Adjunct Professor of Epidemiology and Health Policy
Public Health Leadership Program
School of Public Health
University of North Carolina
APINUN ARAMRATTANA, M.D., PH.D.
Assistant Professor of Family Medicine, and
Research Institute of Health Sciences
Chiang Mai University
Chiang Mai, Thailand
SAMUEL A. BOZZETTE, M.D., PH.D.
Professor of Medicine and of International Relations
University of California,
San Diego, and
Senior Natural Scientist
Santa Monica, Calif.
DAVID D. CELENTANO, SC.D.
Professor and Director
Infectious Disease Epidimiology Program, and
Department of Epidemiology
Johns Hopkins Bloomberg School of Public Health
MATHEA FALCO, J.D.
THEODORE M. HAMMETT, PH.D.
Abt Associates Inc.
ANDREI P. KOZLOV, PH.D.
Professor and Director
St. Petersburg University
St. Petersburg, Russia
SHENGHAN LAI, M.D., PH.D.
Department of Pathology
Johns Hopkins School of Medicine
AJAY MAHAL, PH.D.
Assistant Professor of International Health Economics
Department of Population and International Health
Harvard School of Public Health
RICHARD S. SCHOTTENFELD, M.D.
Professor of Psychiatry
Yale University School of Medicine
New Haven, Conn.
SUNITI SOLOMON, M.D.
Voluntary Health Services
Y.R. Gaitonde Centre for AIDS Research and Education
ALICIA GABLE, M.P.H
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