What has been achieved in HIV prevention, treatment and care for people who inject drugs, 2010-2012? A review of the six highest burden countries

School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia. Electronic address: .
The International journal on drug policy (Impact Factor: 3.19). 09/2013; 25(1). DOI: 10.1016/j.drugpo.2013.08.004
Source: PubMed


In 2010 the international HIV/AIDS community called on countries to take action to prevent HIV transmission among people who inject drugs (PWID). To set a baseline we proposed an "accountability matrix", focusing upon six countries accounting for half of the global population of PWID: China, Malaysia, Russia, Ukraine, Vietnam and the USA. Two years on, we review progress.
We searched peer-reviewed literature, conducted online searches, and contacted experts for 'grey' literature. We limited searches to documents published since December 2009 and used decision rules endorsed in earlier reviews.
Policy shifts are increasing coverage of key interventions for PWID in China, Malaysia, Vietnam and Ukraine. Increases in PWID receiving antiretroviral treatment (ART) and opioid substitution treatment (OST) in both Vietnam and China, and a shift in Malaysia from a punitive law enforcement approach to evidence-based treatment are promising developments. The USA and Russia have had no advances on PWID access to needle and syringe programmes (NSP), OST or ART. There have also been policy setbacks in these countries, with Russia reaffirming its stance against OST and closing down access to information on methadone, and the USA reinstituting its Congressional ban on Federal funding for NSPs.
Prevention of HIV infection and access to HIV treatment for PWID is possible. Whether countries with concentrated epidemics among PWID will meet goals of achieving universal access and eliminating new HIV infections remains unknown. As long as law enforcement responses counter public health responses, health-seeking behaviour and health service delivery will be limited.

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Available from: Steffanie A Strathdee
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    • "While the Russian government does provide free HIV testing, treatment, and other services, it lacks effective control measures targeting the most at risk populations. Syringe exchange programs are run by non-governmental organizations operating without much political or financial support (Degenhardt et al., 2014), and despite the fact that Russia doubled funding for antiretroviral therapy in 2007, in the years that followed, as few as 1% of people who inject drugs who needed such treatment received it (Mathers et al., 2010). Some qualitative evidence suggests that HIV stigma is particularly intense in Russia because of its association with injection drug use, and that this stigma can serve as a major barrier to treatment (Bobrova et al., 2006). "
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    ABSTRACT: Experiences of stigma are often associated with negative mental and physical health outcomes. The present work tested the associations between stigma and health-related outcomes among people with HIV who inject drugs in Kohtla-Järve, Estonia and St. Petersburg, Russia. These two cities share some of the highest rates of HIV outside of sub-Saharan Africa, largely driven by injection drug use, but Estonia has implemented harm reduction services more comprehensively. People who inject drugs were recruited using respondent-driven sampling; those who indicated being HIV-positive were included in the present sample (n = 381 in St. Petersburg; n = 288 in Kohtla-Järve). Participants reported their health information and completed measures of internalized HIV stigma, anticipated HIV stigma, internalized drug stigma, and anticipated drug stigma. Participants in both locations indicated similarly high levels of all four forms of stigma. However, stigma variables were more strongly associated with health outcomes in Russia than in Estonia. The St. Petersburg results were consistent with prior work linking stigma and health. Lower barriers to care in Kohtla-Järve may help explain why social stigma was not closely tied to negative health outcomes there. Implications for interventions and health policy are discussed. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Full-text · Article · Apr 2015 · Social Science & Medicine
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    • "Meanwhile, prescription opioid use has also increased in Australia, and high rates of opiate use continue to be documented in Southwest Asia and Europe (United Nations Office of Drug Control, 2014). Injection opiate use is a major driver of overdose mortality and morbidities (Degenhardt et al., 2014a), including HIV (Mathers et al., 2008) and hepatitis C virus (HCV) infections (Nelson et al., 2011), and represents an urgent public health priority. Methadone, an effective and highly cost-effective long acting opioid agonist used as a substitution drug for opiate dependence, has become a central component of the public health response to injection opiate use globally (Mathers et al., 2010; Nosyk et al., 2013). "
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    ABSTRACT: While regulatory frameworks governing methadone maintenance therapy (MMT) require highly regimented treatment programs that shape treatment outcomes, little research has examined the effects of regulatory changes to these programs on those receiving treatment, and located their experiences within the wider context of social-structural inequities. In British Columbia (BC), Canada, provincial regulations governing MMT have recently been modified, including: replacing the existing methadone formulation with Methadose(®) (pre-mixed and 10 times more concentrated); prohibiting pharmacy delivery of methadone; and, prohibiting pharmacies incentives for methadone dispensation. We undertook this study to examine the impacts of these changes on a structurally vulnerable population enrolled in MMT in Vancouver, BC. Qualitative interviews were conducted with 34 people enrolled in MMT and recruited from two ongoing observational prospective cohort studies comprised of drug-using individuals in the six-month period in 2014 following these regulatory changes. Interview transcripts were analysed thematically, and by drawing on the concept of 'structural vulnerability'. Findings underscore how these regulatory changes disrupted treatment engagement, producing considerable health and social harms. The introduction of Methadose(®) precipitated increased withdrawal symptoms. The discontinuation of pharmacy delivery services led to interruptions in MMT and co-dispensed HIV medications due to constraints stemming from their structural vulnerability (e.g., poverty, homelessness). Meanwhile, the loss of pharmacy incentives limited access to material supports utilized by participants to overcome barriers to MMT, while diminishing their capacity to assert some degree of agency in negotiating dispensation arrangements with pharmacies. Collectively, these changes functioned to compromise MMT engagement and increased structural vulnerability to harm, including re-initiation of injection drug use and participation in high-risk income-generating strategies. Greater attention to the impacts of social-structural inequities on MMT engagement is needed when modifying MMT programs, especially as other jurisdictions are adopting similar changes. Comprehensive environmental supports should be provided to minimize adverse outcomes during transitional periods. Copyright © 2015. Published by Elsevier Ltd.
    Full-text · Article · Apr 2015 · Social Science [?] Medicine
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    • "Ukraine is one of the few countries in Eastern Europe and Central Asia that has implemented relatively progressive evidence-informed HIV prevention and treatment services for PWIDs (UNAIDS, 2014). The effectiveness of harm reduction programs and policies, including outreach and peer education, condom distribution, voluntary HIV testing, provision of antiretroviral therapy (ART) and needle/syringe exchange programs (NSEPs), however, have been inadequately scaled-to-need to meet HIV prevention and treatment efforts (Degenhardt et al., 2014; Wolfe, Carrieri, & Shepard, 2010). Opioid substitution therapy (OST) in Ukraine was first introduced using buprenorphine maintenance (BMT) in 2004 (Bruce, Dvoryak, Sylla, & Altice, 2007; Lawrinson et al., 2008) and followed by methadone maintenance treatment (MMT) in 2008 (Schaub, Chtenguelov, Subata, Weiler, & Uchtenhagen, 2010) to address HIV prevention and treatment challenges including risky drug injecting practices and poor access to and retention in ART. "
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    ABSTRACT: Aims: Opioid substitution therapy (OST) is an evidence-based HIV prevention strategy for people who inject drugs (PWIDs). Yet, only 2.7% of Ukraine’s estimated 310,000 PWIDs receive it despite free treatment since 2004. The multi-level barriers to entering OST among opioid-dependent PWIDs have not been examined in Ukraine. Methods: A multi-year mixed methods implementation science project included focus group discussions with 199 PWIDs in five major Ukrainian cities in 2013 covering drug treatment attitudes, beliefs, knowledge and experiences with OST. Data were transcribed, translated into English and coded. Coded segments related to OST access, entry, knowledge, beliefs and attitudes were analyzed among 41 PWIDs who were eligible for but had never received OST. Findings: A number of programmatic and structural barriers were mentioned by participants as barriers to entry to OST, including compulsory drug user registration, waiting lists and limited number of treatment slots. Participants also voiced strong negative attitudes and beliefs about OST, especially methadone. Their perceptions about methadone’s side effects as well as the stigma of being a methadone client were expressed as obstacles to treatment. Conclusions: Despite expressed interest in treatment, Ukrainian OST-naïve PWIDs evade OST for reasons that can be addressed through changes in program-level and governmental policies and social-marketing campaigns. Voiced OST barriers can effectively inform public health and policy directives related to HIV prevention and treatment in Ukraine to improve evidence-based treatment access and availability.
    Full-text · Article · Mar 2015 · Drugs: Education Prevention and Policy
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