Reaching ambitious HIV treatment targets for people who use drugs requires efforts to protect privacy, to promote access to opioid substitution treatment and to keep people out of prison, the 25th International Harm Reduction Conference (HR17) in Montréal, Canada, heard earlier this month.
Attention to HIV and related issues at the conference was overtaken by more high profile topics such as spiraling overdose rates in North America, human rights crises for people who use drugs in countries such as the Philippines and Russia, and the growth of amphetamine-type substances and their use in different contexts and by different populations.
A single session on HIV treatment for people who use drugs, sponsored by the World Health Organization (WHO), focused on the UNAIDS 90-90-90 HIV treatment targets, the barriers getting in the way of progress on these targets for people who inject drugs, and examples of promising practice from Ukraine and Pakistan describing community-based programmes that are successful in improving access to HIV testing and antiretroviral therapy (ART) services for people who use drugs.
Recently published data from Eastern Europe show the extent of the challenge in improving the continuum of care for people who use drugs. In St Petersburg, Russia, only 9.7% of people who use drugs were receiving antiretroviral treatment, and in northern Estonia, only 32%. Very low rates of HIV testing were compounded by low rates of transition to HIV care. High alcohol use, lack of medical insurance and greater injecting frequency were each associated with a lower uptake of HIV care, suggesting that interventions addressing multiple barriers are needed to improve linkage to care among people who use drugs (Heimer 2017).
Annette Verster of WHO asked whether differentiating HIV treatment access and retention by key populations provides meaningful information about people who use drugs and their access to treatment.
WHO endorses a differentiated approach to HIV testing and treatment, for key populations and others at increased risk, to intensify HIV testing efforts where the yield of HIV-positive results is likely to be highest. This differentiated approach responds to the problem of large-scale HIV testing programmes that produce only small numbers of HIV-positive results, suggesting a lack of tailoring of HIV testing strategies.
However, Verster pointed to a number of limitations in the quest to gather differentiated HIV testing and treatment data on people who use drugs, because of the costs and because of the requirement to register individuals as drug users on databases that lack sufficient privacy controls.
Verster described the different methods available to collect HIV testing and treatment information on drug users: surveys, case-based surveillance and programmatic data, and the limitations of each approach. She concluded by arguing that these methods are technically difficult and costly, they may be unreliable and they are likely to risk the safety of people whose behaviour is often criminalised and stigmatised. Indeed, Verster argues that the settings that pose the greatest challenges for disaggregating data on drug users are likely to be the same settings as those where access is poorest for people who use drugs, and where people who use drugs are criminalised, incarcerated and stigmatised.
Verster argued that a lack of data is no excuse for not acting to improve access for people who use drugs, and that barriers to services are often known.
The author of this article and Daniel Wolfe, Director of the International Harm Reduction Development Program at Open Society Foundations drew attention to several policy problems that need to be addressed in order to tackle poor access to testing and treatment.
High rates of incarceration of people who use drugs represent a major access barrier. According to UNAIDS, between 50 and 90% of people who use drugs will be incarcerated at some point. Mass incarceration keeps people who use drugs away from ART and other health services.
Incarceration can be long or short term, and HIV treatment and drug treatment services such as opiate substitution treatment are rarely available for people in prison or pre-trial detention. While people move in and out of incarceration, accessing and adhering to ART is very difficult. Keeping people out of prison becomes an important intervention to improve HIV treatment access, McLean and Wolfe argued.
The problems of HIV testing – the first 90 – was a strong focus of this session, with most presenters discussing the difficulties of making progress in this area. Privacy and drug user registration emerged as a key policy problem. For many people who use drugs who are being tested for HIV, their HIV status and their status as a drug user is information that governments and law enforcement agencies own and use to further discriminate against drug users and their families. Registration of drug users on government databases was described as a significant problem.
Hostility to the practice of opioid substitution therapy (OST) and lack of funding for OST is another policy issue that needs to be tackled to improve ART uptake and retention in care. Sustaining people who use drugs on antiretroviral treatment requires better access to opioid substitution treatment. Opioid substitution treatment is known to improve access to and retention on ART yet coverage of OST programmes for people who use drugs is very poor (Low 2016).
Despite these barriers, efforts are underway in some countries to address these problems and accelerate access to ART for people who use drugs. Presenters from Ukraine and Pakistan described harm reduction-oriented services that are successful in reaching HIV-positive drug users, helping them access ART services and helping them with adherence support programmes.
In Ukraine, Alliance for Public Health has developed a large-scale programme that uses peer networks to target and tailor HIV testing services, and then a peer-base case management system to accelerate ART access for those who test positive. Programme Manager Pavlo Smyrnov described dramatic increases in detection of HIV-positive drug users, along with a 50% increase in the rate of newly diagnosed drug users who access ART following a peer-based case management intervention.
The session concluded with a discussion about the importance of community-based and outreach-based harm reduction services as the key platform for the delivery of a variety of services for people who use drugs, including ART services.
Heimer R et al. Engagement in HIV care and its correlates among people who inject drugs in St Petersburg, Russian Federation and Kohtla-Järve, Estonia. Addiction, advance online publication, 4 May 2017.
Low A et al. Impact of opioid substitution therapy on antiretroviral therapy outcomes: a systematic review and meta-analysis. Clin Infect Dis 63:8, 2016.