Review highlights unmet needs, chance of hidden epidemics and opportunity in countries where people who inject drugs in region of high risk and lagging response
In Afghanistan, where an estimated 83 percent of the world’s supply of heroin is produced, a gram of the drug could be bought for as little as $4 at a time when it would cost about $200 elsewhere. About three quarters of that heroin is trafficked through neighboring Iran and Pakistan. And yet, authors of a recently released review note, available data on HIV epidemics among people who inject drugs in the region is scarce, scattered and of varying reliability. The review, HIV among People Who Inject Drugs in the Middle East and North Africa, in fact, appears to be the first attempt to examine the state of the epidemic among that marginalized population exposed to high risks of transmission in the region.
The review, of 192 reports of prevalence and incidence of HIV, as well as other sexually transmitted infections and hepatitis C, numbers of people injecting drugs, and of risks and knowledge of risks among them, with information from 23 countries, shows a range of both data collection efforts and responses. The data, as well as the trends they point to, are likely incomplete. Overall, though, the authors note, the evidence found of emerging epidemics offer an opportunity for effective responses through harm reduction efforts, including needle and syringe exchange programs.
The data also show, however, in both responses and epidemiology, the potential for HIV to spread more rapidly in the region.
The authors note that Libya, where laws restricted sales of needles and syringes from pharmacies in the late 1990s, now is home to the the highest prevalence of HIV among people who inject drugs in the region; an estimated 87 percent are infected with HIV in the capital city.
They also point to settings where HIV prevalence escalated sharply, following previous trends in hepatitis C prevalence. In addition, they point to the chances for “bridges” between people who inject drugs and the general population to fuel countries’ overall incidence. In some countries, the authors found, the majority of women infected with HIV acquired the virus through a spouse or other male sex partner who injects drugs. In Iran, they cite, people injecting drugs account for 56 percent of the country’s total HIV incidence, with an additional 12 percent comprised by their sexual partners. Those sexual partners could transmit infections to others, adding to the impact, the authors note. The review also points to the existence of little data, but great vulnerability among women who inject drugs, additionally at risk through partners who also inject drugs and through sex work.
While harm reduction efforts are scant across the region, nine countries have needle and syringe exchange programs and five countries have opioid substitution programs. Iran, the report says, “remains the leader” in harm reduction responses, with not only the highest coverage of needle and syringe exchange, but possibly the only such programs in prisons, and services by and for women who inject drugs.