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1 HIV/AIDS in Injecting Drug Users At the end of 2005, some 38.6 million people were living with HIV (UNAIDS, 2006). An estimated 4.1 million people were newly infected with HIV in 2005 (UNAIDS, 2006). While sub-Saharan Africa remains hardest hit by the HIV/AIDS epidemic, major epidemics are also emerging in other parts of the world, mainly as a result of injecting drug use. This report focuses on high-risk1 countries—namely in Eastern Europe, the Commonwealth of Independent States, and significant parts of Asia—where injecting drug use is, or is on the verge of becoming, the primary driver of the HIV epidemic. This chapter begins by exploring the epidemiology of HIV among injecting drug users (IDUs) in those regions, including prevalence of injecting drug use, prevalence of HIV among IDUs, and transmission routes. The chapter next focuses on the wide range of individual and structural (or environmental) factors that affect IDUs’ risk of HIV infection. Examples of individual-level factors discussed in this chapter include severity of dependence, type of drug used, and existence and severity of co-occurring psychiatric disorders. Examples of structural-level factors include proximity to overland trafficking routes, drug laws and enforcement practices, injecting environment and culture, and stigma and discrimination. The chapter then describes specific interventions to prevent HIV among 1 In this report, such countries are labeled as “high-risk,” indicating that injecting drug use is, or is on the verge of becoming, the primary driver of the HIV epidemic.
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IDUs. The committee has grouped these interventions into three broad categories: drug dependence treatment (including both pharmacotherapies and psychosocial interventions), sterile needle and syringe access, and outreach and education. Other important HIV prevention and treatment strategies that are not specific to IDUs, such as voluntary counseling and testing, antiretroviral treatment, and prevention and treatment of sexually transmitted diseases, are also briefly discussed, but are not part of the committee’s evidence review. The chapter ends with a brief discussion of the global coverage of HIV prevention services for IDUs. EPIDEMIOLOGY OF HIV IN INJECTING DRUG USERS Data on the size of the IDU population and HIV prevalence among IDUs are scarce. Estimating the size of the IDU population is difficult because drug use is an illegal and stigmatized activity. IDUs are often hidden and avoid settings where researchers might obtain data for fear of arrest or stigmatization (Magnani et al., 2005; Des Jarlais et al., 2001). HIV prevalence is difficult to estimate because many areas also lack the capacity to systematically monitor HIV infections among IDUs (Des Jarlais et al., 2001). Areas with routine HIV surveillance collect most of the data at institutions such as prisons, jails, and drug abuse treatment and outreach centers, which do not necessarily represent the IDU population at large (Dehne et al., 2002). The United Nations Reference Group on HIV/AIDS Prevention and Care among IDUs recently developed estimates of the prevalence of injecting drug use, prevalence of HIV infection among IDUs, and the availability of prevention services worldwide, with a focus on developing and transitional countries (Aceijas et al., 2004). These estimates were compiled from a comprehensive review of published and unpublished documents for the period 1998–2003. Estimates were based on information available for 130 countries and territories.2 The authors assigned a strength of evidence rating to each source based on the type of information and methods used in calculating the estimate. The strength of evidence supporting estimates of both IDU prevalence and HIV prevalence among IDUs was generally poor. Approximately 95 percent of the estimates of IDU prevalence and 64 percent of HIV prevalence estimates received a rating of “low,” meaning that estimates lacked any supporting technical information (Aceijas et al., 2004). As a result of these limitations, estimates of IDU population size and HIV 2 Data were missing for 119 countries and territories (Aceijas et al., 2004).
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prevalence among IDUs should be interpreted with caution (Aceijas et al., 2004). Based on these data, the UN Reference Group estimated that there are 13.2 million injecting drug users worldwide (Aceijas et al., 2004). Of those, an estimated 8.8 million live in Eastern Europe and Central, South, and Southeast Asia (Aceijas et al., 2004; UNAIDS, 2006), and an estimated 10.3 million (or 78 percent) live in developing or transitional countries (see Figure 1.1). A major driver of the rapid expansion of HIV in these and other areas is injecting drug use, accounting for about one-third of new infections outside sub-Saharan Africa. Worldwide, an estimated 10 percent of all HIV infections are related to injecting drug use, although that proportion is estimated to be much higher in certain regions of the world (UNODC, 2005; WHO, 2005a; Aceijas et al., 2004). Primarily because of injecting drug use, Eastern Europe, Central Asia, and the Commonwealth of Independent States have witnessed as much as a 20-fold increase in the number of people living with HIV in less than a decade (UNAIDS, 2006). The majority of these individuals live in Ukraine and the Russian Federation. In Russia, an estimated 940,000 people were living with HIV at the end of 2005, and unsafe injecting practices are the main cause of HIV infection among people under the age of 30 (UNAIDS, 2006). In Ukraine, unsafe injecting practices and unprotected sex are both responsible for alarming increases in HIV infection. In some cities in Ukraine, 58 percent of IDUs are HIV-seropositive (UNAIDS, 2006). Young people are especially affected by the increase in HIV transmission among IDUs in the Commonwealth of Independent States, as many IDUs are below the age of 25 and began injecting before the age of 20 (UNAIDS, 2005). Many other countries in Eastern Europe, Central Asia, and the Commonwealth of Independent States are also experiencing growing HIV epidemics. Currently, injecting drug use fuels the HIV epidemic in Uzbekistan, Kazakhstan, and Armenia (UNAIDS, 2006). Tajikistan is witnessing a smaller, yet rapidly evolving epidemic, illustrated by a study in its capital Dushanbe, which found an HIV prevalence of 12 percent among IDUs (Stachowiak et al., 2006). Sexual transmission continues to drive the epidemics of countries such as Belarus, Azerbaijan, Georgia, and Romania. However, both the continued increase in the number of injecting drug users and the rising HIV prevalence rates among both injecting drug users and sex workers could signal that a more generalized epidemic is looming (UNAIDS, 2006). In Asia, an estimated 8.3 million people were living with HIV at the end of 2005, with India home to more than two-thirds of these individuals (UNAIDS, 2006). While sexual transmission is still the predominant route of transmission in India, injecting drug use is driving the epidemic in the
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FIGURE 1.1 Estimates of IDU populations by region (in millions). NOTE: Estimates are based on data collected from 130 countries from 1998–2003. SOURCE: Reprinted, with permission, from the United Nations Office on Drugs and Crime, 2004 and the UN Reference Group on HIV/AIDS Prevention and Care among IDUs in Developing and Transitional Countries, 2004.
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northeast states of Manipur, Mizoram, and Nagaland, and increasingly in the major cities of Chennai, Mumbai, and New Delhi (UNAIDS, 2006). In Vietnam, injecting drug use and sex work are the main drivers of the HIV epidemic, with prevalence among IDUs rising from 9 percent in 1996 to 32 percent in 2003 (UNAIDS, 2006). Although Thailand has witnessed dramatic declines in the levels of HIV and sexually transmitted infections since the late 1990s, HIV among IDUs remains a major problem (UNAIDS, 2006). As of September 2004, Malaysia had approximately 61,000 cases of HIV infection (Chawarski et al., 2006), with some 76 percent resulting from injecting drug use (WHO, 2003a). While the sharing of contaminated injecting equipment remains a large risk factor for HIV, sexual transmission, particularly in northern peninsular Malaysia, accounts for an estimated 12–56 percent of HIV infections among heroin users (Lye et al., 1994; Singh and Crofts, 1993). Other countries such as Indonesia and Bangladesh report low HIV prevalence among the general population, but the potential remains for explosive epidemics among high-risk groups such as IDUs and sex workers. Although data are very limited for Myanmar, an estimated one in three IDUs was HIV-seropositive in 2004 (UNAIDS, 2006). In China, injecting drug users accounted for almost half of the people living with HIV in 2005 (UNAIDS, 2006). Sexual transmission has also grown substantially in the past few years, and evidence shows HIV infection spreading to the general population. Injecting drug use is also driving the HIV epidemic in Iran, accounting for two-thirds of infections (Razzaghi et al., 2006). A recent study found that 15 percent of male IDUs attending drug treatment centers in Tehran were HIV-seropositive (UNAIDS, 2006). Injecting drug use also accounts for a significant portion of HIV transmission in some countries outside these high-risk regions. In South America and the Caribbean, Brazil and Puerto Rico also report HIV prevalence among IDUs greater than 20 percent, as do some areas of Argentina and Uruguay (UNAIDS, 2006). Recent studies also suggest that injecting drug use is a growing problem that accounts for a small but increasing proportion of new HIV cases in Kenya, Nigeria, South Africa, Tanzania, Mauritius, and Egypt (Dewing et al., 2006; McCurdy et al., 2006; Beckerleg et al., 2005). In North America, approximately 20 percent of new infections in the United States in 2004 were attributed to injecting drug use (CDC, 2005). Canada’s small HIV epidemic is driven by unprotected sex between men although HIV infection among women is rising, mostly due to unprotected sex and unsafe injecting drug use (UNAIDS, 2006). In Western and Central Europe, heterosexual transmission remains the driver of the HIV epidemic, while the epidemic in Australia and New Zealand is mainly driven by unprotected sex between men (UNAIDS, 2006).
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BOX 1-1 Amphetamine-Type Stimulants Methamphetamine and related amphetamine compounds (amphetamine-type stimulants, or ATS) are among the most commonly abused drugs, with an estimated 35 million users worldwide (Colfax and Shoptaw, 2005). These drugs target the central nervous system, increasing energy, alertness, disinhibition, and feelings of euphoria while decreasing appetite (Colfax and Shoptaw, 2005). Methamphetamine use can cause neurological toxicity, cardiovascular problems, dental decay, and skin infections (Colfax and Shoptaw, 2005). Chronic use is also associated with severe neurotoxicity and long-term cognitive impairment and mood disorders, although some cognitive functions can return after prolonged abstinence from the drug (Colfax and Shoptaw, 2005). Methamphetamine use is also associated with increased high-risk sexual behavior. Use of ATS has grown rapidly in recent years, perhaps because ingredients are readily available in over-the-counter medicines (such as cough medicine), and large quantities can be easily produced in small, mobile laboratories (UNODC, 2002). Increases in ATS use are being reported in many areas of the world, with the most rapid expansions occurring in countries of Southeast Asia, including Hong Kong SAR, Indonesia, Thailand, Myanmar, Malaysia, Singapore, the Philippines, China, Lao People’s Democratic Republic, Cambodia, and Vietnam. A major expansion of “yaba”—as amphetamines in tablet form are known in Thailand—prompted an intensive crackdown by the Thai government in its War on Drugs to decrease both supply and demand (Poshyachinda et al., 2005) (see Appendix C). ATS can be snorted, ingested, smoked, or injected, depending on the form in which the drug is available and cultural practices (UNODC, 2002). Most countries in Southeast Asia report that the preferred routes of administration are smoking, sniffing, and inhaling. However, the Philippines and Vietnam are reporting the injection of ATS (UNODC, 2002). In addition to opiates3 which are commonly injected, amphetamine-type stimulants and cocaine are also major injectable drugs of abuse in many high-risk countries (UNAIDS, 2006). Regions and countries vary widely in the types of drugs people use and their injecting behavior. In Latin America, for example, cocaine is the most commonly injected drug, although opium derivatives are increasingly available (Magis-Rodriguez et al., 2002). In Southeast Asia, methamphetamine production, trafficking, and use are rising dramatically, with an unknown percentage of users transitioning to injecting amphetamine use (see Box 1.1) (Kulsudjarit, 2004). 3 “Opiates are a group of psychoactive substances derived from the poppy plant that includes opium, morphine, codeine and some others. The term ‘opiate’ is also used for the semisynthetic drug heroin that is produced from poppy compounds. The term ‘opioids’ refers to opiates and other semisynthetic and synthetic compounds with similar properties” (WHO et al., 2004, p. 4).
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In South Asia, besides heroin, IDUs commonly inject synthetic painkillers, benzodiazepines, and other pharmaceuticals (Ghys, 2005). ROUTES OF HIV TRANSMISSION The sharing of contaminated injecting equipment is the primary mode of HIV transmission among IDUs, accounting for up to 80 percent of all HIV infections among IDUs in Eastern Europe and Central Asia (UNAIDS, 2006; UNODC, 2005). Sexual transmission from HIV-infected drug injectors to their sex partners is becoming an important secondary route of spread (Grassly et al., 2003), as is perinatal transmission from HIV-infected female IDUs or HIV-infected female sex partners of IDUs to their children. Transmission Through Contaminated Injecting Equipment HIV epidemics driven by injecting drug use tend to spread more rapidly than epidemics spread by sexual transmission, because exposure to the virus occurs more frequently, and because needles are more efficient at transmitting it than sex. In many parts of the world, HIV prevalence reached 40 percent and above among IDUs just 1 to 2 years after HIV entered the IDU population (Rhodes et al., 1999a). For example, in Edinburgh, an HIV outbreak started in 1983 among IDUs who had been injecting for only a year or two and spread rapidly through the IDU population, skyrocketing from 5 to 57 percent within 2 years (Robertson et al., 1986). Examples of this trend also exist throughout Southeast Asia and Eastern Europe (Crofts et al., 1998; Rhodes et al., 1999b). A recent review concluded that HIV had spread rapidly in Belarus, Kazakhstan, Moldova, Russia, and Ukraine by the late 1990s, with 50–90 percent of new HIV infections occurring among IDUs (Rhodes et al., 1999b). While not the focus of this report, contaminated injecting equipment is also a mode of transmission for viral hepatitis (see Box 1.2). Sexual Transmission Sexual transmission from HIV-infected IDUs to their sex partners is becoming an important route of HIV transmission. Drug use is highly correlated with unsafe sexual practices, including unprotected sex, multiple partners, or exchanging sex for money or drugs (UNODC, 2005). Many studies have found links between injecting drug use, commercial sex, and risky sexual behavior, resulting in high rates of HIV prevalence among sex workers who are also IDUs. Studies have shown that drug injecting sex workers are more willing to engage in unprotected sex, and
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BOX 1-2 Viral Hepatitis There are five identified types of viral hepatitis (A-E) and each one is caused by a different virus (CDC, 2003). Hepatitis C and B are the two most common types found among injecting drug users. Hepatitis C is an inflammation of the liver caused by the hepatitis C virus (HCV). Although the infection can be asymptomatic or mild, it can become chronic in over half of those infected. Among these, about half will eventually develop cirrhosis (scarring) or liver cancer (CDC, 2003). It is spread primarily by contact with the blood of an infected person, e.g., through receipt of contaminated blood or blood products, sharing needles or other injecting equipment, and through accidental needle-sticks or sharps exposures (CDC, 2003). Far less frequently it is spread sexually or from an infected mother to her baby. Recent studies show that HCV may survive on environmental surfaces at room temperature at least 16 hours, but not longer than 4 days (CDC, 2003). While there is regional variation, studies show that HCV prevalence among IDUs is often as high as 60 percent (Hagan, 1998; Garfein et al., 1998; Shapatava et al., 2006; Zhao et al., 2006). In addition to the sharing of needles and syringes, the sharing of other injecting and drug preparation equipment such as cookers used to melt drugs, cotton used to filter out particles when drawing the drug into the syringe, and water used to rinse syringes, has been associated with HCV infection (Diaz et al., 2001; Hagan et al., 1999, 2001; Hahn et al., 2002; Thorpe et al., 2002). There is no vaccine available for the prevention of HCV infection. Hepatitis B is a disease caused by another bloodborne pathogen, the hepatitis B virus (HBV). HBV also produces liver inflammation and can cause lifelong infection, cirrhosis of the liver, liver cancer, liver failure, and death (CDC, 2003). Besides the potential for transmission through receipt of contaminated blood and blood products and through contact with other infectious bodily fluids (such as saliva or semen) and tissues, HBV is also spread through having unprotected sex with an infected person, by sharing drugs, needles, or other injecting equipment, through accidental needle-sticks or sharps exposures, or from an infected mother to her baby (CDC, 2003). It is stable on environmental surfaces for at least 7 days and has been transmitted between children living closely together in household settings. There is a vaccine to prevent HBV infection. more likely to have a non-paying sex partner who is an IDU (Pisani et al., 2003; Paone et al., 1999). National survey data also reveal a link between injecting drug use and high-risk sexual activity among commercial sex workers. In Ho Chi Minh City, Vietnam, 49 percent of injecting sex workers are infected with HIV, compared with 19 percent of those who use drugs but do not inject, and 8 percent of those who do not use drugs at all (MAP, 2005a). In Manipur, India, HIV prevalence was found to be 57 percent among sex workers who were also IDUs, compared with 20 percent among sex workers who did not inject drugs (Panda et al., 2001).
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There are reports of high percentages of sex workers who also inject drugs. Estimates of the proportion of female sex workers who inject drugs include: From 25 to 80 percent in the Russian Federation (Lowndes et al., 2003). Some 30 percent across the Commonwealth of Independent States of the former Soviet Union (UNODC, 2005). Between 20 and 50 percent in Eastern Europe (UNODC, 2005). Between 10 and 25 percent in Central Asia (UNODC, 2005). In addition, many IDUs sell sex as a means to obtain drugs or money to buy drugs (Lowndes et al., 2003). Data from several cities in countries such as Kazakhstan, Uzbekistan, and Kyrgyzstan show that while only a relatively small percentage of female sex workers in these cities inject drugs (6–14 percent), most female IDUs sell sex (56–67 percent) (MAP, 2005b). Studies in different Russian cities show that 15–50 percent of female IDUs are involved in sex work (Lowndes et al., 2003; Dehne and Kobyshcha, 2000). Finally, some non-injecting women are infected with HIV by their injecting sexual partner or husband. In a study in Sao Paulo, 40 percent of non-injecting HIV-infected females had acquired the virus through unsafe sexual activity with IDUs (UNODC, 2005). In another study in India, 45 percent of non-injecting wives of HIV-seropositive IDUs were themselves infected with HIV, with 97 percent reporting sexual activity only with their husbands (Panda et al., 2000). Perinatal Transmission Perinatal transmission from infected female IDUs and infected partners of IDUs to their children is another growing concern. Transmission from a mother to a child can occur during pregnancy, labor and delivery, or breastfeeding (WHO, 2004a). The magnitude of IDU-associated perinatal transmission has not been systematically examined, but some studies suggest that it is a major problem. For example, according to one report, most HIV-infected infants born between 1996 and 2001 in the Russian Federation apparently had mothers who were either IDUs or sexual partners of IDUs (UNODC, 2005). FACTORS INFLUENCING HIV RISK AMONG IDUS A range of individual and structural factors can affect an IDU’s risk of contracting HIV. Examples of factors specific to the individual include severity of drug dependence, preferred drug, and existence and severity of
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co-occurring psychiatric disorders, among others. Structural factors contribute to the “risk environment” for injecting drug users, affecting their HIV-related risks and health outcomes by creating an environment in which HIV is more likely to be transmitted (Rhodes et al., 2005). Examples discussed in the following section include proximity to drug trafficking routes, drug laws and law enforcement practices, socioeconomic and political stability, injecting environment and culture, and stigma and discrimination.4 Individual and structural factors converge to affect the likelihood that an IDU will engage in high-risk behavior, such as sharing of injecting equipment, more frequent injecting, commercial sex work, unprotected sex, and multiple sex partners. Individual-Level Risk Factors Severity of Dependence Severity of dependence can influence the likelihood that someone will inject, the frequency of injection, and the sharing of contaminated equipment. Two studies by Gossop and colleagues using the same sample (n=408) examined the association between severity of heroin dependence with sharing injecting behavior and sexual behavior. One study (Gossop et al., 1993a) found that severity of heroin dependence was positively related to the occurrence and frequency of sex-for-money and sex-for-drugs transactions. The other study (Gossop et al., 1993b) found that more severely dependent heroin users were more likely to have shared injecting equipment. More dependent users also appeared to use heroin in private settings and to be at greater risk of sharing with dealers, possibly because of their urgent need during drug withdrawal. Other studies also found that severity of drug use, as measured by frequency of injection and injection of drug combinations, is significantly associated with sharing of equipment (Klee et al., 1990; Watters et al., 1994). Type of Drug Used The type of drug an IDU uses influences the frequency of injection and the risk of HIV transmission. An early epidemiological study in San Francisco found that injection cocaine use significantly increased the risk of HIV infection (Chaisson et al., 1989). Because cocaine has a relatively short half- 4 See Rhodes et al. (2005) for a more comprehensive discussion of structural factors influencing the risk environment for IDUs.
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life and is highly addictive, people may inject it more frequently, with reports of 10 times or more a day, compared with 1 to 3 injections per day among heroin-dependent IDUs (Chaisson et al., 1989). Even after controlling for frequency of use, Chaisson and colleagues found that cocaine injectors had a higher prevalence of HIV. They found that cocaine injection was associated with other behaviors that increased the risk of HIV: cocaine injectors were more likely to report sharing injecting equipment, using drugs in shooting galleries, and “booting” drugs (withdrawing blood into the syringe before injecting). Other studies in Montreal, Vancouver, and Toronto also found that cocaine use was positively associated with HIV infection (Bruneau et al., 2001; Strathdee et al., 2001, Lamothe et al., 1993). Methamphetamine increases sexual drive and decreases inhibitions, leading to high-risk sexual behaviors (Colfax and Shoptaw, 2005). Methamphetamine use also increases the likelihood of engaging in high-risk sexual behavior such as unprotected sex and increased number of partners, and the acquisition of HIV and other sexually transmitted infections (Colfax and Shoptaw, 2005; Molitor et al., 1998; Molitor et al., 1999). Presence and Severity of Co-Occurring Psychiatric Disorders Co-occurring psychiatric disorders are common among drug-dependent individuals. Some psychiatric disorders precede the onset of drug dependence, while others are precipitated by chronic drug use (O’Brien et al., 2004). Opioid addicts have high rates of depression and antisocial personality disorder (Kosten and Rounsaville, 1986; Brooner et al., 1997). Similarly, cocaine abusers have high rates of affective and anxiety disorders, attention deficit disorder in childhood, and personality disorders (Schottenfeld et al., 1993). Methamphetamine users have high levels of depression, anxiety, and personality disorders (Chen et al., 2003; Zweben et al., 2004). Long-term methamphetamine use can also lead to psychosis (Chen et al., 2003), and amphetamine withdrawal commonly results in symptoms of severe depression (Urbina and Jones, 2004). Studies have demonstrated a consistent positive association between psychiatric problems, particularly depressive disorders, and sharing of injecting equipment (Hawkins et al., 1998; Mandell at al., 1999). Depression may influence IDUs’ risk of HIV infection by altering their perception of the threat of HIV infection, reducing their ability to judge the consequences of their decisions, decreasing their ability to cope with stressful events, and increasing the likelihood of careless behavior (Stein et al., 2003). Research has found that greater severity of depression is associated with increased sharing of injecting equipment, and the risk of acquiring or transmitting HIV (Stein et al., 2003).
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