The provision of programmes to prevent the spread of HIV and hepatitis among people who inject drugs (PWID) is inadequate in many countries around the world and presents a critical public health problem, comprehensive reviews by Australian researchers from the National Drug and Alcohol Research Centre at University of New South Wales (UNSW) have found.
Authors estimate in the two reviews of the global prevalence of injecting drug use and of interventions to prevent the spread of blood borne viruses among people who inject drugs, that 15.6m people have recently injected drugs. Of these, 18% are living with HIV infection and 52% test positive for hepatitis C antibody.
Yet despite evidence that needle and syringe programmes (NSP) and opioid substitution therapy (OST) reduce HIV and HCV infections, they are still not being implemented in many places, and few people can access them in many countries, the authors found.
Australia is one of only four countries worldwide with high coverage of both NSP and OST – the others are Austria, the Netherlands and Norway. In Australasia 1.1% of PWID are living with HIV compared with 25% of PWID in Eastern Europe, 36% in Latin America, 18% in sub Saharan Africa and 19% in South Asia. By contrast, the prevalence of hepatitis C among PWID is more evenly spread – 57% of the people who inject drugs in Australia and New Zealand test positive for hepatitis C antibodies, compared with 64% in Central Europe, 55% in North America and 50% in East and South-East Asia.
“Across all countries a substantial number of people who inject drugs are living with HIV or HCV and are exposed to multiple adverse risk environments that increase health harms,” says UNSW’s Professor Louisa Degenhardt, lead author of the paper reviewing prevalence of injecting drug use and HIV and hepatitis in this population.
The reviews of global prevalence of injecting drug use and of provision of programs to prevent the spread of blood borne viruses is the first to be conducted since 2008, although the results are not directly comparable due to different and more sophisticated data collection techniques, and better country specific record keeping. Evidence of injecting drug use was found in an additional 33 countries compared with the last review – predominantly from sub Saharan Africa.
Just over half (52%) of the countries with evidence of injecting drug use had needle syringe programs and medical treatment to encourage reductions in injecting – opioid substitution therapy – was available in less than half of all countries identified (48%).
“Coverage of HIV and HCV prevention interventions for PWID remains poor and is likely to be insufficient to effectively prevent HIV and HCV transmission. Scaling up of interventions for PWID remains a crucial priority for halting the HIV and HCV epidemics,” says UNSW’s Dr Sarah Larney, lead author of the paper on global coverage of interventions. “The presence of interventions alone is not sufficient; the greatest prevention benefits are reported when NSP and OST are implemented in high coverage and in combination,” Larney adds.
The three regions worldwide with the highest populations of people who inject drugs, east and south-east Asia, Eastern Europe and North America, all had poor provision of needle syringe programs and opioid substitution therapy. HIV prevalence in these countries was high ranging from 9% in North America to 25% in Eastern Europe. By contrast, only 1% of people who inject drugs in Australia and New Zealand are living with HIV.
“Several countries in these regions have experienced recent HIV outbreaks as well as persistently high HCV prevalence among PWID,” write the authors. For example, Russia, which has almost 2m people who inject drugs, nearly 30% of whom have HIV and 69% of whom have hepatitis C, does not provide OST and has very limited access to NSP, the authors found.
Background: People who inject drugs (PWID) are a key population affected by the global HIV and hepatitis C virus (HCV) epidemics. HIV and HCV prevention interventions for PWID include needle and syringe programmes (NSP), opioid substitution therapy (OST), HIV counselling and testing, HIV antiretroviral therapy (ART), and condom distribution programmes. We aimed to produce country-level, regional, and global estimates of coverage of NSP, OST, HIV testing, ART, and condom programmes for PWID.
Methods: We completed searches of peer-reviewed (MEDLINE, Embase, and PsycINFO), internet, and grey literature databases, and disseminated data requests via social media and targeted emails to international experts. Programme and survey data on each of the named interventions were collected. Programme data were used to derive country-level estimates of the coverage of interventions in accordance with indicators defined by WHO, UNAIDS, and the UN Office on Drugs and Crime. Regional and global estimates of NSP, OST, and HIV testing coverage were also calculated. The protocol was registered on PROSPERO, number CRD42017056558.
Findings: In 2017, of 179 countries with evidence of injecting drug use, some level of NSP services were available in 93 countries, and there were 86 countries with evidence of OST implementation. Data to estimate NSP coverage were available for 57 countries, and for 60 countries to estimate OST coverage. Coverage varied widely between countries, but was most often low according to WHO indicators (<100 needle-syringes distributed per PWID per year; <20 OST recipients per PWID per year). Data on HIV testing were sparser than for NSP and OST, and very few data were available to estimate ART access among PWID living with HIV. Globally, we estimate that there are 33 (uncertainty interval [UI] 21–50) needle-syringes distributed via NSP per PWID annually, and 16 (10–24) OST recipients per 100 PWID. Less than 1% of PWID live in countries with high coverage of both NSP and OST (>200 needle-syringes distributed per PWID and >40 OST recipients per 100 PWID).
Interpretation: Coverage of HIV and HCV prevention interventions for PWID remains poor and is likely to be insufficient to effectively prevent HIV and HCV transmission. Scaling up of interventions for PWID remains a crucial priority for halting the HIV and HCV epidemics.
Sarah Larney, Amy Peacock, Janni Leung, Samantha Colledge, Matthew Hickman, Peter Vickerman, Jason Grebely, Kostyantyn V Dumchev, Paul Griffiths, Lindsey Hines, Evan B Cunningham, Richard P Mattick, Michael Lynskey, John Marsden, John Strang, Louisa Degenhardt