People who inject drugs risk being left behind as countries make efforts to scale up antiretroviral treatment unless greater efforts are made to develop services that meet the needs of this group, according to speakers at Controlling the HIV Epidemic with Antiretrovirals: From Consensus to Implementation, a conference that took place in London this week.
Anna Zakowicz of the Global Network of People Living with HIV (GNP+) appealed to physicians to support the efforts of community-based activists to deliver services in settings where people who inject drugs are marginalised by policy makers.
“We need a movement from your side to give us – the community – power to deal with the epidemic” she said. “We are not taken seriously when we want to open clinics but we will continue to do testing [through outreach projects] even though it is illegal for us to do it.”
The conference, organised by the International Association of Providers in AIDS Care (IAPAC) and the British HIV Association (BHIVA) in partnership with UNAIDS and Public Health England, brought together experts for discussion of how to expand treatment access in order to realise the full benefits of antiretroviral therapy (ART) in preventing new HIV infections.
Best case scenario
The Canadian province of British Columbia shows the potential for people who use drugs to be brought into care – and for treatment to reduce new infections.
Prof. Julio Montaner of the University of British Columbia presented further data from the British Columbia HIV treatment programme, the first in Canada to embrace a 'seek and treat' approach to HIV diagnosis and care.
Modelling suggests that British Columbia has seen a 1% decline in HIV diagnoses for every 1% increase in treatment coverage, although the reduction in new diagnoses has been most pronounced in people who inject drugs. Further falls in deaths, AIDS diagnoses and TB diagnoses have occurred since 2006. The 'seek and treat' strategy has also resulted in a substantial increase in CD4 cell count at diagnosis, indicating that testing activities are diagnosing people earlier in the course of infection.
The reduction in new diagnoses has been most pronounced in people who inject drugs, among whom new diagnoses have fallen by around 60% since 2007.
Other Canadian provinces have not adopted a similarly aggressive 'seek and treat' policy. Most provinces have seen little or no reduction in new HIV diagnoses over the past decade. Two western provinces – Saskatchewan and Manitoba – have seen large increases in HIV diagnoses in recent years.
“We lack the federal leadership to implement what has been shown to work on the west coast of our country,” said Prof. Montaner. While the provincial government in British Columbia made HIV a health priority after being presented with projections of the money that could be saved by pursuing a more aggressive strategy, “the federal government has a moralistic attitude towards the whole problem and that is reflected in the statistics”.
In particular, Canada’s federal government has attempted to shut down a supervised injecting site in a district of Vancouver with a high concentration of injecting drug users. In 2011, Canada’s Supreme Court rejected the attempts of Canada’s Health Minister to close the facility, ruling that the supervised injecting facility had “saved lives and improved health”.
Although the reduction in HIV diagnoses in British Columbia is routinely attributed to its 'seek and treat' policy, the contribution of harm reduction services remains unquantified.
Optimising services for people who inject drugs
Professor Frederick Altice of Yale University School of Medicine and Public Health reminded the meeting that outside sub-Saharan Africa, one-third of all new HIV infections occur in people who inject drugs, and in countries where HIV prevalence is increasing most rapidly, 70 to 80% of infections have occurred in people who inject drugs.
Achieving very high rates of viral suppression among people who inject drugs presents a distinct set of challenges regarding engagement in care and adherence to treatment, he explained. In the United States, for example, people who inject drugs are more likely to be incarcerated, less likely to have health insurance, less like to see the same physician at every encounter with the health system and more likely to have substance abuse problems that affect treatment adherence. People who inject drugs are also less likely to have stable housing.
Research in the US has shown a very strong tendency among physicians to defer antiretroviral therapy among people who inject drugs, even in people in need of immediate ART. Just over half of prescribers surveyed would defer treatment in people with CD4 counts below 200 if they injected drugs daily, while 70% would defer treatment at a CD4 count of 350 if injecting took place daily, despite the US DHHS recommendation to treat immediately at these CD4 cell strata.
Altice and colleagues previously reported that a greater duration of buprenorphine opioid substitution therapy was associated with much higher rates of ART prescription and treatment adherence. People who took buprenorphine for the first nine months of antireretroviral therapy were much more likely to achieve a viral load below 400 copies/ml (62 vs 18%) and were much more likely to be prescribed ART.
Service delivery models also need to adapt to the full healthcare needs of people who inject drugs, said Altice. A study of service integration in Ukraine found that integration of HIV, TB, harm reduction and opioid substitution services at one site was associated with higher rates of ART receipt and CD4 monitoring.
Incarceration represents a period of high risk for people who inject drugs, for HIV infection, for loss from care and for non-adherence to HIV treatment. A study in Ukraine found that only one-in-five people who were injecting drugs prior to incarceration received ART in prison, even though half continued to inject in jail and 42% shared needles with an average of four other people.
After release from jail, women are at particularly high risk of loss from care and interruption of therapy, according to unpublished data showing that only 18% of women released from jail had an undetectable viral load six months later.
Access to treatment: location matters
Access to treatment for people who inject drugs is critically determined by location. In eastern Europe and central Asia, where the HIV epidemic is highly concentrated in people who inject drugs and men who have sex with men, 75% of people who need treatment do not get it, Olga Stefanyshyna of the Ukrainian Community Advisory Board told a community consultation on treatment as prevention that preceded the meeting.
In Ukraine, advocacy by people living with HIV and their families shifted government attitudes towards the provision of treatment, she said. The children of people living with HIV wrote to the President of Ukraine demanding treatment for their parents, and 46,000 people are now receiving ART in Ukraine, up from 24,000 in 2011. Improvements in treatment access have been achieved in part by competition between generic drug manufacturers, but prices have also been brought down by an activist anti-corruption drive, which identified major distortions in prices.
Slide presentations from the conference are available at the conference web page.