First, the good news.
HIV prevalence around the world is starting to stablize, with overall growth in numbers of new infections slowing in most areas.
But not all populations are experiencing this trend.
“In Kenya and Tanzania, overall HIV incidence is stable, but the number of HIV infections among injection drug users (IDUs) is rising,” said Phillip Nieburg, MD, MPH, a senior associate at the Center for Strategic & International Studies (CSIS). This trend has been most pronounced in Eastern Europe and Central Asia, but new infections among injections drug users in East Africa are on the rise.
Nieburg discussed the trend before a small crowd Tuesday to launch a new CSIS report, “HIV Prevention among Injection Drug Users in Kenya and Tanzania: New opportunities for progress,” which he co-authored with Lisa Carty, deputy director of the CSIS Global Health Policy Center.
Compared with other non-occupational exposure types, with the exception of blood transfusion, needle sharing has the highest risk of HIV transmission, with 67 per 10,000 exposures, with unprotected receptive anal intercourse the next highest with 50 per 10,000 exposures. The health and community workers in Kenya and Tanzania reported being appalled by how few IDUs understood this risk, Nieburg said.
Kenya, with a population of 41 million, has an estimated 30,000 IDU, among whom an estimated 32 percent share needles and 36 to 43 percent are HIV-infected. The story in Tanzania is quite similar: among a population of 42 million on the mainland, approximately 25,000 to 50,000 are IDU, among whom an estimated 42 percent are HIV-positive and 33 to 54 percent share needles. The HIV prevalence among IDU in both countries is skewed toward women, where there is a high overlap between sex work and injection drug use. According to the report authors, female injection drug users face even more stigma than their male counterparts and are even less likely than male IDUs to gain access to appropriate prevention and treatment services.
One in three HIV infections outside of sub-Saharan Africa is among IDU and, “there is a huge opportunity to avoid a much bigger problem among IDU in East Africa,” said discussion panelist Zoe Hudson of the Open Society Foundations. Evidence for effective HIV prevention interventions for IDUs is very strong – some of the best evidence of effectiveness we have in HIV prevention – Hudson said, and although it is remarkably effective and inexpensive, people are not able to access services due to stigma and legal consequences of admitting drug use, including police misconduct in many countries. Hudson also noted that in a number of countries that were part of the former Soviet Union, where ART is available and where IDUs dominate the population of persons with HIV, IDUs are still underrepresented on the HIV treatment rolls.
The report lists nine essential interventions in comprehensive programs for people who inject drugs:
- Needle and syringe programs
- Medication-assisted therapy and other drug dependency treatment
- HIV testing and counseling
- Antiretroviral therapy
- Prevention and treatment of sexually transmitted infections
- Condom programming for people who use drugs and their sexual partners
- Targeted information, education and communication programs
- Viral hepatitis diagnosis, treatment and immunization
- Tuberculosis prevention, diagnosis and treatment
The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) program issued revised guidance in July of 2010 that permits the provision of medication-assisted therapy (e.g. methadone for drug addiction) and provision of clean injection needles and syringes for IDUs, and Nieburg and Carty’s report seeks to evaluate the epidemic and program implications soon after the change in guidance.
“The future depends on our effectiveness in moving from the celebration of this new guidance to really working hard in terms of implementation,” said Richard Needle, PhD, MPH, senior public health advisor at the Office of the U.S. Global AIDS Coordinator, also a discussion panelist. “Under-resourcing of this is an unfortunate reality.”
Obstacles to effective treatment and prevention programs in Tanzania and Kenya that Nieburg noted included a lack of awareness of the addictiveness of heroin, uncertain funding, society-wide stigma, uncertain interaction between the legal and health systems, and limited access to clean needles and syringes for those unable to enter treatment programs. The amount of HIV prevention funding devoted to the IDU population in both countries is miniscule– 0.8 percent in Kenya and 2.7 percent in Tanzania. IDU represented about 1.6 percent of the total PEPFAR prevention funding budget in 2010.
According to the UNAIDS 2010 report on the global AIDS epidemic, of the seven countries in the world with HIV epidemics increasing by more than 25 percent from 2001 to 2009, five are in Eastern Europe and Central Asia – where the HIV epidemic is fueled by infection among IDU and their sexual contacts. Nieburg made the point that even in a generalized epidemic, there is still a lot of transmission among core groups.
There are four important take-away messages from the report, according to Carty. First, the striking gender disparities in the epidemic need to be noted and taken into account, especially on the psycho-social level as women are more subject to violence and stigma, and are therefore harder to identify. Next, the value and effectiveness of treatment and support peer programs can be strengthened. Carty then highlighted the need to work in an integrated fashion, with the Global Fund to Fight AIDS, Tuberculosis and Malaria and other programs, and the need to advocate for other groups to adopt the U.S. revised guidance on IDU. Fourth, Carty said there is still a long way to go, and a lot can happen to derail progress – including legal obstacles, tighter funding in the future, and tricky and controversial politics on the topic.
The report, not yet available on the CSIS website, represents part of a larger year-long effort CSIS has launched to examine the intersection of IDU and HIV prevention, and options for U.S. policy in Africa, Eastern Europe and Asia.