Marcia Frellick

March 05, 2014

BOSTON — Clean-needle programs and opiate-substitution therapy have helped to reduce HIV infection in people who inject drugs, but barriers to such interventions are fueling a public health problem.

"We have all the evidence" to reduce transmission, said Adeeba Kamarulzaman, MBBS, from the University of Malaya in Kuala Lumpur in Malaysia. In fact, "in many instances, particularly with needle-exchange programs, it's not that difficult to do. But it's not happening," she told Medscape Medical News.

She discussed HIV and injection-drug use here at the 2014 Conference on Retroviruses and Opportunistic Infections.

There are 60 million injection-drug users worldwide, and approximately 3 million are infected with HIV. Although the world is seeing an overall reduction in the number of infected drug users, some populations still wrestle with very high infection rates, she reported.

"Unfortunately, the reality is that for every 100 people using drugs who should be receiving opiate-substitution therapy, only about 8 are," Dr. Kamarulzaman said. The average clean-needle use is 2 per month, but most heroin users inject "2 to 4 times a day."

There are some areas of progress, particularly in Asia. In China, opiate-substitution therapy increased 30% from 2009 to 2011. In Vietnam, there has been a rapid scale-up of clean-needle and opiate-substitution programs and of antiretroviral therapy use.

For every 100 people using drugs who should be receiving opiate-substitution therapy, only about 8 are.

Unfortunately, the news is not as good in Russia, where the number of people participating in clean-needle programs has been decreasing and where opiate-substitution therapy is not supported. And in the United States, after the initial ban on federal funding for needle-exchange programs was lifted, it is now back in place.

Some groups in particular are marginalized, Dr. Kamarulzaman noted.

For instance, women drug users have much higher rates of HIV infection than their male counterparts, but often find access to services at opiate-substitution therapy centers more difficult. Centers are often run by men and have no provisions for childcare or related services because women are less often thought of as injection-drug users, she explained.

Adolescents are also falling into the gap where access to interventions is limited.

In the Ukraine, for instance, UNICEF estimates that 50,000 youth 10 to 19 years of age are injection-drug users, but "only about 1000 are currently receiving services," Dr. Kamarulzaman said.

In the prison population, drug use is rampant and the risk for HIV infection is high.

Being incarcerated can offer an opportunity for drug users to receive treatment, but it is also "a terrible incubator for HIV, tuberculosis, and many other diseases," she said.

The stigma attached to drug use has been a barrier to proper care, Dr. Kamarulzaman explained.

The reluctance of regular prescribers of antiretroviral therapy to prescribe to people who continue to use drugs was documented in a survey conducted in Canada and the United States (J Int AIDS Soc. 2012;15:10). In fact, 24.2% of providers said they would defer antiretroviral therapy for HIV-infected patients with a CD4+ cell count of 200 cells/mm³ if the patient actively injected drugs, and 52.4% said they would defer treatment if the patient injected daily.

By withholding treatments "that we know can have impact on reducing HIV transmission around the world, we actually disarm ourselves of being able to address this epidemic, in terms of both public health policy and plain old humanity," said Steve Shoptaw, PhD, director of the UCLA Center for Behavioral and Addiction Medicine in Los Angeles.

Much of that comes from worldwide misconceptions about addiction, he told Medscape Medical News.

"The concept of addiction is seen as a defect or a moral flaw, as opposed to the brain disease that it is. The idea of providing opioid-substitution therapy in the context of other harm-reduction approaches, like syringe exchange and providing access to retroviral therapies, is not necessarily a shared concept across political groups," he said.

Dr. Kamarulzaman reports receiving grants from Merck. Dr. Shoptaw has disclosed no relevant financial relationships.

2014 Conference on Retroviruses and Opportunistic Infections (CROI). Presented March 3, 2014.


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