Injecting drug use: focused HIV prevention works
11 May 2007
Injecting drug use is estimated to account for nearly one-third of new infections outside sub-Saharan Africa, but fewer than 8% of injecting drug users receive HIV prevention services.
Drug users not only face physical risks of HIV infection, they are also vulnerable to HIV because of their social and legal status. Illegal in many countries, drug use is punishable by incarceration and is highly stigmatized, which further marginalizes people with drug dependence problems. As a consequence, injecting drug users are often not able or willing to access HIV services for fear of recrimination.
This month’s UNAIDS Best Practice review features several HIV prevention programmes that prove ‘high coverage site’ programmes reaching out to more than 50% of the injecting drug user populations with focused prevention interventions, can prevent, stabilize and even reverse HIV epidemics among injecting drug users.
“The scaling up of HIV prevention and even more so care and treatment for drug users is lagging behind in the overall AIDS response. The current HIV prevention coverage rate of 8% shows the problem,” said Anindya Chatterjee, UNAIDS Advisor on Prevention and Public Policy. “We know that focused HIV prevention programmers have been successful in reducing HIV prevalence among people who inject drugs . In countries and cities where harm reduction programmes have been implemented early and on a large scale, HIV prevention programmes have been successful––down to less than 5% in some cases,” he said
The document, entitled ‘High Coverage Sites: HIV prevention among injecting drug users in transitional
and developing countries’ was developed from a report first commissioned by UNAIDS to investigate sites in developing and transitional countries which were regarded by international authorities as “high coverage sites” i.e. where more than 50% of injecting drug users had been reached by one or more HIV prevention programmes. In all, seven sites were examined, including Soligorsk, Belarus; Pskov, Russian Federation; Sumy, Ukraine; Dhaka, Bangladesh; Rajshahi, Bangladesh; Hong Kong Special Administrative Region (Hong Kong SAR), People’s Republic of China and Salvador, Brazil.
Found to prove that high-level coverage can be attained by programmes specifically addressing HIV among injecting drug users, the report later became part of the UNAIDS ‘Best Practice Collection’ .
Common features of high coverage programmes
As the Best Practice document underlines, effective approaches to addressing HIV among injecting drug users are controversial in many parts of the world. Therefore, across the programmes featured, substantial work was devoted to overcoming community fears and government concerns about the initiatives. This was generally achieved through advocacy at many levels, starting with the community in the immediate neighbourhood where services were provided, through formal and informal meetings, public information campaigns, involvement by programme managers in multi-sectoral AIDS and drugs committees and, in most cases, by carefully building relationships with selected representatives from the mass media.
In one example highlighted, a joint media campaign organized by the Department of Health, the Narcotics Division of the Security Bureau and the Information Services Department of the Hong Kong Special Administrative Region Government was carried out in 2002 through TV, radio and web to increase public understanding of drugs and AIDS-related issues and the role of methadone, aiming to change public attitudes towards drug users and methadone clients.
Across the featured programmes, regular evaluations and dissemination of results assisted in building political and community support. In some cases, political support resulted in laws and policies, which provided for HIV-specific services, and government funding to ensure programme implementation. “Sustainability is most likely in sites where this type of political commitment exists,” the Best Practice states.
Central to all the featured programmes in the document, the involvement of law enforcement services was a critical determinant for the success of the programmes and crucial in achieving high coverage of injecting drug users. “Programme clients needed to be able to attend needle exchange sites, or methadone or HIV treatment clinics without fear of arrest and outreach workers carrying new and used needles and syringes needed to be able to work without supplies being confiscated,” the report states.
In most of the sites studied, law enforcement services entered into flexible and trust-based working relationships with programme staff, and even participated as full partners in planning and expanding the programmes. The programme manager at the Soligorsk site in Belarus said, “Relations with police are excellent and this has made a real difference— for example, the regular patrol route was altered so that police vehicles were less likely to pass the Programme at the Centre for Hygiene and Epidemiology during its opening hours, meaning drug users were more inclined to attend.”
The Best Practice also underlines the importance of involving injecting drug users as programme staff to achieve high level coverage and sustainability of the programmes. An important factor in the initial growth of the programme in Pskov, Russian Federation was hiring an active injecting drug user as an outreach worker. Without this involvement, the document states, it would have been impossible to establish relations with the injecting drug user community as several previous attempts had been made by the AIDS Centre staff with no results. Here and in other examples, establishing strong and trusting relations with drug users was key to accessing injecting drug user networks.
In the example from Salvador, Brazil, the programme aims at addressing drug using neighbourhoods rather than just drug users individually. This approach means that a wide range of services have been established to form a comprehensive set of drug and HIV-prevention activities as well as general health and social assistance. While the main objective is to provide services to injecting drug users, crack cocaine smokers and other non-injecting drug users, services also reach out to their families, sexual partners, neighbours and other people living in drug-using neighbourhoods.
Across all the examples within the Best Practice document it is underlined that the programmes are unique to the social, political and cultural settings in which they are implemented.”Rather than replicate models developed by other countries, programme planners and implementers studied the principles underlying programmes and designed appropriate HIV programmes for their sites,” the report states.
However, the report underlines that success may not be immediate–indeed, none of the programmes described achieved high level coverage in the first year of operation—and this means that funding for such programmes needs to be solid, flexible and sustainable. “Funding should not only be flexible enough to allow for growth in service use; a commitment is also needed for at least two years to ensure that programmes reach sufficient numbers of injecting drug users,” notes the report.
Taking into consideration the many challenges faced by the programmes, the Best practice concludes that the coverage achieved through the focused interventions has led to the avoidance or delay of AIDS epidemics among injecting drug users in a number of the countries.. In Bangladesh; Hong Kong SAR; Pskov, Russian Federation; and Sumy, Ukraine, high HIV prevalence among injecting drug users has been avoided despite high prevalence in neighbouring provinces or countries with similar cultures and levels of injecting drug use.
“The best practice case studies show that achieving a high coverage among drug users is highly possible and both HIV prevention and treatment programmes for drug users need dramatic scaling up,” said Anindya Chatterjee.
Download the Best Practice: ‘High Coverage Sites: HIV prevention among injecting drug users in transitional and developing countries’
Read UNAIDS' Technical Policies on injecting drug users
Other UNAIDS Best Practice reviews:
Learning from experience
A faith-based response to HIV in Southern Africa
Traditional healers join the AIDS response
Focused AIDS programmes in Asia and the Pacific