PEPFAR: HIV prevention for injection drug users in Africa a growing issue

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While sexual transmission is the leading driver behind the spread of HIV, it has been estimated that globally, injection drug use accounts for at least 10% of new infections globally. In some countries injection drug users (IDUs) are at the centre of the epidemic. Preventing the spread of HIV in this (and from this) marginalised population will be necessary to reverse the epidemic in Eastern Europe and southeast Asia.

Several presentations at the Implementers meeting addressed prevention activities among this population.

Injection drug use spreading to Africa

Even though injection drug use has been perceived as a European or Asian issue, Dr. Richard Needle presented a comprehensive review of the literature suggesting that drug use is increasing on the African continent, in particular, in coastal countries such as Nigeria, Tanzania, Kenya and South Africa. Heroin is the drug most likely to be injected, and the percentage of IDUs sharing syringes within the past six months ranges from 11% in Nigeria to 27% in Kenya. Several small studies suggest that the HIV prevalence in these populations ranges between 8.9% in Nigeria, to 19.4% in South Africa, 29-31% in Tanzania and between 22.9% to 50% in Kenya.

A survey presented by a team from South Africa’s Medical Research Council demonstrated that injection drug use is indeed a growing problem in South Africa, although many participants still have a perception that of it as a “white” problem. However the survey included sex workers, men who have sex with men, and injection drug users from white, black, Indian and coloured populations — and drug use is widespread among all groups with an astounding variety of substances. Heroin is not the only drug being injected —increasingly people are now shooting up crystal methamphetamine, cocaine and even MDMA.

Glossary

VCT

Short for voluntary counselling and testing.

IDU

Injecting drug user.

cost-effective

Cost-effectiveness analyses compare the financial cost of providing health interventions with their health benefit in order to assess whether interventions provide value for money. As well as the cost of providing medical care now, analyses may take into account savings on future health spending (because a person’s health has improved) and the economic contribution a healthy person could make to society.

community setting

In the language of healthcare, something that happens in a “community setting” or in “the community” occurs outside of a hospital.

Another study from Africa focused solely on heroin use. According to Clement Deveau, Kenya currently has an estimated 30,000 injection drug users and the problem is growing. Although Kenya has an HIV prevalence of 8%, the potential HIV prevalence among IDUs is over 50%. Prevention services for this population are extremely rare in Kenya so PEPFAR is funding a community outreach programme to reach this population.

Finding clean needles

US federal policies do not permit support of clean needle exchange programmes, an intervention that has repeatedly been demonstrated to be a cost-effective way to reduce HIV transmission but which religious and social conservatives see as “enabling” drug use. The sad truth is that lack of a clean needle (or fear of HIV or Hepatitis C transmission) is not going to deter a heroin addict from shooting up. However, access to clean needles can draw them into the programme and protect him or her from infection long enough to provide them with ongoing opportunities to use the rehabilitation services (such as methadone substitution therapy) that the programme offers.

But in a political climate where religious conservatives, more obsessed about the “sin” than what happens to the “sinner,” have great influence over US policy, it is unlikely that political policies will change, at least for the next few years. But even though PEPFAR-supported programmes do not provide clean needles to IDUs, they can tell them where to find them or how to clean them (a much less effective alternative).

According to one presentation, in Vietnam, pharmacies are open late at night to provide IDUs with a place to get clean needles. However, it is difficult to say how truly accessible these services are, or whether an IDU can go there without fear of prosecution. In Thailand, for example, needles are also available at pharmacies, but pharmacies are watched by the police who quickly arrest IDUs, often in such a brutal and violent manner that the IDU is dead before reaching detention.

Outreach programmes and other services

As a result, IDU’s in Thailand, and many other settings, keep a very low profile. In order to find this hidden vulnerable population, many projects, including projects in Thailand, Vietnam and Kenya use outreach workers drawn from the community (former IDUs). The community peer outreach members know where to find the IDUs, are inexpensive and if properly trained, can effectively refer IDUs to other services.

However, according to Deveau, these workers are not always entirely reliable and can be a challenge to work with. “Using ex-drug addicts provides easier access to drug users but poses other challenges in work performance and reliability, he said.

A valid question might be whether utilising these workers might not simply be exposing them to temptation and a study should perhaps be conducted to monitor the ongoing health and well-being of these community-based workers.

PEPFAR-based prevention programmes contribute to other services for IDUs — but it can be a challenge to get the IDUs to accept them. Although the Kenyan project conducted a survey in their repeat contacts reporting declines in injecting, from 94% to 85% and in needle sharing, from 41% to 15%, Deveau did not seem to have great confidence in the findings because “IDUs deny injecting” he said.

He noted that in Kenya, many drug users refused to take advantage of HIV testing (VCT), and “health prevention was a low priority for drug users not having health problems. Addicts view services as a diversion form their priority to seek money to support their addiction,” said Deveau. In the future, the project is going to put more emphasis on mobile services which are more accessible in the hopes that that will increase client participation. But the lack of interest in these services begs the question of whether providing free clean needles would not be a more effective way to keep drawing the clients in.

However, the Thailand project reported several improvements in behaviour associated with its efforts to provide information about sexual risk reduction and condoms, VCT and methadone treatment. VCT may be particularly important for prevention efforts among IDU who may not not bother to protect themselves because they commonly assume themselves to already be infected. The flip side of this however, is that fatalism associated with an increase in alcohol and drug use often increase when people learn that they are HIV-infected, so it is crucially important that VCT services for IDUs are closely linked with HIV care and counselling services.

According to most of the presentations, unfortunately, getting IDUs into care and support programmes remains a challenge.

References

Deveau C et al. Prevention of HIV/AIDS among drug users as a vulnerable population. The 2006 HIV/AIDS Implementers Meeting of the President’s Emergency Plan for AIDS Relief, Durban, South Africa, abstract 89, 2006.

Yongwanitchit K et al. Bangkok Metropolitan Administration (BMA) outreach program to reduce HIV risks for injecting drug users. The 2006 HIV/AIDS Implementers Meeting of the President’s Emergency Plan for AIDS Relief, Durban, South Africa, Abstract 93, 2006.

Needle R et al. Injection drug use in sub-Saharan Africa: emergence of an under-recognized

HIV transmission risk. The 2006 HIV/AIDS Implementers Meeting of the President’s Emergency Plan for AIDS Relief, Durban, South Africa, Abstract 121, 2006.

Parry C et al. HIV and drug use among injection drug users (IDUs), commercial sex workers

(CSWs) and men who have sex with men (MSM) in South Africa. The 2006 HIV/AIDS Implementers Meeting of the

President’s Emergency Plan for AIDS Relief, Durban, South Africa, Abstract 126, 2006.

Chau LTM. Community-based outreach for high-risk injection drug using populations in an emergency plan country: Vietnam 2004–2005. The 2006 HIV/AIDS Implementers Meeting of the President’s Emergency Plan for AIDS Relief, Durban, South Africa, Abstract 127, 2006.