CROI 2014: Plenary on evidence for harm reduction need for HIV in people who use drugs is a first for conference

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CROI2014BOSTON, MASS – It’s the driver of at least 70 percent of the HIV rates in most of the countries where epidemics continue to climb, as well as of rising rates of hepatitis, but the roles of injecting drug use and responses to it in transmission, prevention and treatment of the virus has never before been the subject of a plenary talk here at the Conference on Retroviruses and Opportunistic Infections, Adeeba Kamarulzaman of the University of Malaya in Kuala Lumpur, Malaysia, began her talk this morning by noting. In the meantime, she noted, study after study has added to a massive and weighty body of evidence, “that these tools work.”

So, she added, “Fasten your seatbelts.”

What followed was a roundup of data and literature reviews from around the world — China, Viet Nam, Ukraine, the United States, and Kamarulzaman’s own country, Malaysia — showing the harm to public health that is increased by punitive responses to drug use, and reduced by provision of clean needles, opiate substitutes, integrated treatment and targeted evidence-based approaches to the most marginalized of people who use drugs: women, transgender individuals, people involved in sex work, and adolescents.

No discussion of HIV and drug use would be complete, Kamarulzaman continued, without attention to the role that prisons have played in adding to the challenges of all of that. Prisons, where people who use drugs generally end up, and where drug use rates can exceed use on the outside, along with forced and consensual sex, shared razors and unsafe tattooing represent “terrible incubators for HIV, TB and hepatitis,” Kamarulzaman said. And in her country, as well as many others, the majority of people imprisoned were sentenced for drug crimes of nonviolent, personal drug use. It is a trend that began more than 40 years ago, she noted, when U.S. President Richard Nixon declared a “war on drugs.”

Obstacles within and outside of prison walls that continue to include failures to address the health needs of people who use drugs, Kamarulzaman said, have raised the question of whether it is a population among whom HIV treatment as prevention can work. The obstacles are considerable, she conceded, because they impact continuums of care, and in turn, adherence to antiretroviral treatment needed to suppress the virus. But the answers to those problems exist, she added, noting that provision of opiate substitute therapy can improve adherence to HIV treatment.

In addition, harm reduction measures that include opiate substitution and needle exchange make good economic sense, by reducing healthcare costs by lowering HIV infection rates, she said, reviewing World Bank data showing the impact of these responses, in the Ukraine, Pakistan, Thailand and Kenya.

She pointed to Portugal where decriminalization of drug use has led to steep declines in incarceration rates, and where that has freed law enforcement authorities to focus on drug traffickers.

Finally, she said, stigmas and bias surrounding drug use must be addressed — starting with health providers.

“The end of AIDS is not going to happen,” she concluded, “until we see an end to the war on drugs and the war on drug users.”

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