Harm reduction for people who inject drugs in Ukraine and Tanzania associated with improved HIV prevention outcomes

Image: Distributing clean needles, condoms, and other harm reduction elements in Ukraine. Brendan Hoffman/Global Fund Advocates Network. Creative Commons licence.

NGO-delivered initiatives have tangible benefits for the health of people who inject drugs in terms of HIV and hepatitis C prevention and engagement with HIV care in Ukraine, according to research presented to the 23rd International AIDS Conference (AIDS 2020: Virtual). Clients of NGOs were more likely to have been tested for HIV, use condoms and sterile needles, receive opioid agonist therapy, and if HIV positive, be on antiretroviral therapy.

Separate research with people who inject drugs in Tanzania showed sustained improvements in HIV testing rates and use of sterile injecting equipment over 12 years, while HIV prevalence fell dramatically over the same time period.

The studies show the investment in services for people who inject drugs can achieve sustained reductions in risk behaviour, enhance engagement with the HIV treatment cascade and help reduce rates of HIV infection in this major risk group. Their results are especially timely as Ukraine’s economic status as an upper-middle income country means grants from international donor organisations are being scaled back with the national government expected to assume responsibility for paying for these vital services.

Glossary

adjusted odds ratio (AOR)

Comparing one group with another, expresses differences in the odds of something happening. An odds ratio above 1 means something is more likely to happen in the group of interest; an odds ratio below 1 means it is less likely to happen. Similar to ‘relative risk’. 

opioid agonist therapy (OAT)

Providing users of an illegal drug (such as heroin) with a replacement drug (such as methadone, buprenorphine or naltrexone) under medical supervision. This helps the person reduce the frequency of injections and their dependency on illegal drugs. It is part of a harm reduction approach.

 

 

treatment cascade

A model that outlines the steps of medical care that people living with HIV go through from initial diagnosis to achieving viral suppression, and shows the proportion of individuals living with HIV who are engaged at each stage. 

risky behaviour

In HIV, refers to any behaviour or action that increases an individual’s probability of acquiring or transmitting HIV, such as having unprotected sex, having multiple partners or sharing drug injection equipment.

exclusion criteria

Defines who cannot take part in a research study. Eligibility criteria may include disease type and stage, other medical conditions, previous treatment history, age, and gender. For example, many trials exclude women who are pregnant, to avoid any possible danger to a baby, or people who are taking a drug that might interact with the treatment being studied.

Ukraine has the second worse HIV and hepatitis C epidemic in Europe, second only to Russia. Approximately 1% of the adult population inject drugs. Over a fifth of people who inject drugs are HIV positive and two-thirds have hepatitis C virus (HCV) antibodies. Half of all HIV infections and 80% of HCV cases in Ukraine involve people with a history of injecting drug use.

Since 2003, the Global Fund has financed NGOs to provide services for people who inject drugs in the country. Their services include provision of sterile injecting equipment and condoms, HIV and HCV testing, and linkage to opioid substitution therapy and HIV treatment clinics.

 Dr Adam Trickey from the University of Bristol examined surveillance data collected between 2009 and 2017 to see if contact with an NGO was associated with improved HIV prevention and treatment outcomes among people who inject drugs.

"Investment in services for people who inject drugs can achieve sustained reductions in risk behaviour, enhance engagement with the HIV treatment cascade and help reduce rates of HIV infection."

A total of 42,014 current injecting drug users took part in bio-surveillance surveys in 31 cities across Ukraine, in 2009, 2011, 2013, 2015 and 2017.

About a third of participants were NGO clients, a proportion that remained stable between surveys. A fifth were female. Mean age increased from 31 years in 2009 to 36 years in 2017. This was accompanied by an increase in the mean number of years of injecting, from 11 to 15 years.

Most (82%) injected opioids and 38% had ever been imprisoned. HIV prevalence was 22%, a proportion that was stable between survey rounds. Overall prevalence of HCV antibodies was 53%, increasing from 38% to 64%.

Individuals in contact with NGOs were more likely to be HIV positive, have HCV antibodies, be female and have a history of imprisonment.

Engagement with an NGO had clear benefits in terms of HIV and HCV prevention. Clients of NGOs were more likely to:

  • have ever been tested for HIV (adjusted odds ratio [aOR] 5.53, 95% confidence interval [95%CI]: 5.10-6.00),
  • have tested for HIV in the last year (aOR 3.44, 95%CI: 3.27-3.63),
  • have used condoms at last sexual intercourse (aOR 1.30, 95%CI: 1.23-1.37)
  • have used sterile needles at last injection (aOR 1.37, 95%CI: 1.20-1.57),
  • be currently on opioid agonist therapy (aOR 4.08, 95%CI: 3.38-4.93), and
  • ever have been on opioid agonist therapy (aOR 2.76, 95%CI: 2.53-3.01).

A total of 2251 study participants tested HIV positive as part of the survey (1061 NGO clients; 1190 non-NGO clients). NGO clients were more likely to know they were HIV positive (aOR = 1.40; 95% CI, 1.32-1.48, p < 0.001), be registered with an HIV clinic (aOR = 2.30; 95% CI, 1.82-2.90, p < 0.001) and be on antiretroviral therapy (aOR = 1.52; 95% CI, 1.32-1.76, p < 0.001).

Dr Trickey concluded that contact with a donor-funded NGO had clear benefits, expressing the hope that they would continue to receive funding in the future.

Tanzania

HIV prevention initiatives targeted at people who inject drugs in Tanzania are having a real impact on HIV prevalence rates, Dr Shaaban Haji of the Tanzanian health ministry told the conference.

He presented data from three bio-surveillance studies of people who inject drugs, conducted on Unguja Island in the Zanzibar archipelago. Zanzibar has an overall HIV prevalence below 1%, with infections concentrated in risk groups, including people who inject drugs.

In 2007, 2012, and 2019, the surveys had 499, 408 and 419 participants, respectively. People on opioid agonist therapy were excluded.

Comparison between the 2007 and 2019 surveys showed that the proportion ever tested for HIV increased from 22% to 82%, access to sterile injecting equipment when needed went from 53% to 87% and the proportion of people using sterile equipment the last time they injected increased from 63% to 91%. These changes were all statistically significant.

These increases in testing and reductions in risky injecting were accompanied by a significant reduction in HIV prevalence, which fell from 16% in 2007, to 11% in 2012 and to 5% in 2019.

“Our efforts suggest that preventive interventions targeting people who inject drugs have been well taken up,” Dr Haji concluded. “Although significantly reduced, HIV prevalence and related risk behaviours persist at levels warranting enhanced efforts to reach all people who inject drugs with primary prevention and harm reduction services, especially eliminating the use of non-sterile needles.”

References

Trickey A. Are harm reduction projects for people who inject drugs in the Ukbraine improving HIV prevention and treatment outcomes? 23rd International AIDS Conference, abstract AOC0304, 2020.

Haji S. Progress in HIV prevention intervention uptakes among people who inject drugs in Unguja Island, Zanzibar, Tanzania. 23rd International AIDS Conference, abstract AOC0306, 2020.

Full image credit: Sergei Tkachuk keeps records while distributing clean needles, condoms, and other harm reduction elements at the Step by Step needle exchange program outside the Kyiv City Narcological Clinical Hospital for Social Therapy on Thursday, November 19, 2015 in Kiev, Ukraine. Brendan Hoffman/Global Fund Advocates Network. Image available at www.globalfundadvocatesnetwork.org/campaigns/we-need-the-global-fund-our-stories/ under Creative Commons licence CC BY-NC 4.0.