Articles tagged as "Injecting drug use and HIV prevention"

Supervised injecting facilities

IDU perspectives on the design and operation of North America's first medically supervised injection facility

Small W, Ainsworth L, Wood E, Kerr T. Subst Use Misuse. 2010 Sep 27. [Epub ahead of print]

While the public health benefits of supervised injection facilities (SIFs) have been well documented, there is lack of research examining the views of people who inject drugs regarding the operation of these facilities. This study used 50 semistructured qualitative interviews to explore the perspectives of people who inject drugs on the design and operation of a supervised injection facility in Vancouver, Canada. Although the environment and operation of the supervised injection facility are well accepted, long wait times and limited operating hours, as well as regulations that prohibit sharing drugs and assisted injections, pose barriers to using the supervised injection facility. Modifying operating procedures and expanding the capacity of the current facility could address these barriers.

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Editors’ note: The first officially sanctioned supervised injecting facility (SIF) opened in Switzerland in 1986. Until 2000, only Germany and the Netherlands had joined Switzerland in offering such services in major cities but, since 2000, SIFs have begun operating in Spain, Australia, Canada, Norway, and Luxembourg. They vary in hours, staffing, operating models, etc. but all include professional supervision of hygienic consumption of pre-obtained drugs with the goals of preventing overdose, reducing injecting-related transmission of HIV and other blood borne viruses, and providing an entry point to psychosocial and medical services. Unlike a study conducted in Montreal a decade ago to determine whether people who inject drugs would use a supervised injecting facility if it were to be created (Green et al 13th IHRA conference Slovenia March 2002), this qualitative study gathered views on current functioning of the well-known Vancouver SIF ‘Insite’. Two major concerns voiced were the prohibition on sharing drugs, a prohibition that holds in most SIFs as it is deemed to constitute a form of trafficking, and a prohibition on assisted injecting. Individuals who require assistance to inject are by definition dependent on another person for their safe injection. Some SIFs acknowledge this vulnerability and are able to accommodate such individuals and their injectors. In other countries, some modification to the legal framework may be required to allow these individuals to benefit from this harm reduction service.

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Injecting drug use

 HIV and risk environment for injecting drug users: the past, present, and future.

Strathdee SA, Hallett TB, Bobrova N, Rhodes T, Booth R, Abdool R, Hankins CA. Lancet. 2010;376:268-84.

The authors systematically reviewed reports about determinants of HIV infection in injecting drug users from 2000 to 2009, classifying findings by type of environmental influence. They then modelled changes in risk environments in regions with severe HIV epidemics associated with injecting drug use. Of 94 studies identified, 25 intentionally examined risk environments. Modelling of HIV epidemics showed substantial heterogeneity in the number of HIV infections that are attributed to injecting drug use and unprotected sex. Strathdee and colleagues estimate that, during 2010-15, HIV prevalence could be reduced by 41% in Odessa (Ukraine), 43% in Karachi (Pakistan), and 30% in Nairobi (Kenya) through a 60% reduction of the unmet need of programmes for opioid substitution, needle exchange, and antiretroviral therapy. Mitigation of patient transition to injecting drugs from non-injecting forms could avert a 98% increase in HIV infections in Karachi; whereas elimination of laws prohibiting opioid substitution with concomitant scale-up could prevent 14% of HIV infections in Nairobi. Optimisation of effectiveness and coverage of interventions is crucial for regions with rapidly growing epidemics. Delineation of environmental risk factors provides a crucial insight into HIV prevention. Evidence-informed, rights-based, combination interventions protecting persons who inject drugs’ access to HIV prevention and treatment could substantially curtail HIV epidemics.

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Editors’ note: This paper begins with a systematic review of the existing literature on drug injecting and HIV risk to see to whether research conducted since 2000 has explored the extent to which physical, social, economic, and political environments interact with micro-environmental and macro-environmental factors to confer risk or protection for HIV infection among people who inject drugs. Examples are provided of micro- and macro-environmental physical, social, economic, and political risk factors for HIV infection. Mathematical modelling is then used to estimate the influence of the environment and the potential impact of overcoming environmental impediments to optimal HIV prevention, treatment, care and support. The synergistic effects of reducing unmet need for clean injecting equipment, opiate substitution treatment, and antiretroviral treatment by 60% are modelled for two cities with serious epidemics among people who inject drugs (Odessa, Ukraine and Karachi, Pakistan) and one city with an emerging drug-related epidemic (Nairobi, Kenya). The findings are striking and compel policy change, including promoting the health and recognising the human rights of people who inject drugs. Shifting the focus from individuals to their social and political contexts helps shine light on the social and political institutions involved in harm production. This risk environment approach to epidemiology should be applied to other settings and other populations at risk of HIV infection as a keystone of combination prevention.

 

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Injecting Drug Use

Time to act: a call for comprehensive responses to HIV in people who use drugs

Beyrer C, Malinowska-Sempruch K, Kamarulzaman A, Kazatchkine M, Sidibe M, Strathdee SA. Lancet. 2010; 376:551-63.

The published work on HIV in people who use drugs shows that the global burden of HIV infection in this group can be reduced. Concerted action by governments, multilateral organisations, health systems, and individuals could lead to enormous benefits for families, communities, and societies. The authors review the evidence and identify synergies between biomedical science, public health, and human rights. Cost-effective interventions, including needle and syringe exchange programmes, opioid substitution therapy, and expanded access to HIV treatment and care, are supported on public health and human rights grounds; however, only around 10% of people who use drugs worldwide are being reached, and far too many are imprisoned for minor offences or detained without trial. To change this situation will take commitment, advocacy, and political courage to advance the action agenda. Failure to do so will exacerbate the spread of HIV infection, undermine treatment programmes, and continue to expand prison populations with patients in need of care.

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Editors’ note: This article is a clarion call to action on HIV and drug use. It argues cogently for the evidence-informed, rights-based public health policies that are urgently needed to address continuing HIV transmission among people who inject drugs. Support for the concept of decriminalisation of drug users is found in a panel on the results of Portugal’s pragmatic, humanistic approach – Portugal decriminalised personal consumption and possession for the consumption of drugs in 2000. A second panel highlights the WHO/UNODC/UNAIDS comprehensive approach for HIV prevention, treatment, and care for people who inject drugs. Informative figures show HIV prevalence in people who inject drugs by region and the growth in opium production in Afghanistan from 1980 to 2009. A personal testimonial underscores why compulsory drug detention centres should be closed and replaced by evidence-informed, human-rights-based drug treatment centres. An assessment matrix compares HIV responses to people who inject drugs in China, Malaysia, Russia, Ukraine, Vietnam, and the USA. A further panel lays out clear points of action for each of 6 key stakeholders: governments, ministries of health, donors, providers, researchers, and people who use drugs. If you are short of time, read the panels, figures, and tables of this excellent paper. If you have more time, read the paper – it draws attention to the findings of each of the six overview articles in this Lancet series.

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People who inject drugs—risk environment

Policing drug users in Russia: risk, fear, and structural violence.

Sarang A, Rhodes T, Sheon N, Page K. Subst Use Misuse. 2010;45:813-64.

Sarang and colleagues undertook qualitative interviews with 209 persons who inject drugs (primarily heroin) in three Russian cities: Moscow, Barnaul, and Volgograd. They explored the accounts of persons who inject drugs about HIV and health risk. Policing practices and how these violate health and self, emerged as a primary theme. Findings show that policing practices violate health and rights directly, but also indirectly, through the reproduction of social suffering. Extrajudicial policing practices produce fear and terror in the day-to-day lives of drug injectors, and ranged from the mundane (arrest without legal justification; the planting of evidence to expedite arrest or detainment; and the extortion of money or drugs for police gain) to the extreme (physical violence as a means of facilitating "confession" and as an act of "moral" punishment without legal cause or rationale; the use of methods of  "torture"; and rape). They identify the concept of police bespredel-living with the  sense that there are "no limits" to police power-as a key to perpetuating fear  and terror, internalized stigma, and a sense of fatalist risk acceptance. Police besprediel is analyzed as a form of structural violence, contributing to "oppression illness." Yet, the authors also identify cases of resistance to such oppression, characterized by strategies to preserve dignity and hope. They identify hope for change as a resource of risk reduction as well as escape, if only temporarily, from the pervasiveness of social suffering. Future drug use(r)-related policies, and the state responses they sponsor, should set out to   promote public health while protecting human rights, hope, and dignity. 

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Editors’ note: Reading this article you will learn more than you may have wanted to know about policing practices in these three Russian cities and, in particular, about police bespredel, no limits or restrictions on police power. Being a drug user is not against the law in Russia, while possession and transport are, so planting evidence creates opportunities for arrests. Formal arrest quotas encourage this behaviour and ‘police taxes’, routine extortion of small amounts of money, provide police officers with supplemental income. Coerced provision of sexual services without payment to police is referred to as subbotnik, a term used for semi-volunteer work without payment on non-working days for the benefit of the State. The impact of the policing risk environment described here on HIV risk is both direct (unsafe needle-syringe practices and sex) and indirect through the loss of hope, dignity, self-esteem, and any sense of agency. To learn more about what should be done to address the risk environment and decriminalise drug users, read The Vienna Declaration http://www.viennadeclaration.com/. More than 15,000 scientists and others have signed on so far to its call for evidence-informed, human-rights-based drug policies.

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Injecting Drug Use

Optimal provision of needle and syringe programmes for injecting drug users: A systematic review.

Jones L, Pickering L, Sumnall H, McVeigh J, Bellis MA. Int J Drug Policy. 2010 Feb. [Epub ahead of print]

 The introduction of needle and syringe programmes (NSPs) during the 1980s is credited with averting an HIV epidemic in the United Kingdom and Australia, but hepatitis C (HCV) incidence continues to rise among people injecting drugs. Needle and syringe programmes incorporating additional harm reduction strategies have been highlighted as an approach that may influence HCV incidence. This systematic review sought to determine which approaches to the organisation and delivery of needle and syringe programmes are effective. Fifteen databases were searched for studies published since 1990. Two reviewers screened all titles and abstracts, and data extraction and quality assessment of individual studies were undertaken independently by one reviewer and checked for accuracy by a second. Sixteen studies met the criteria for inclusion. Based on 11 studies there was no evidence of an impact of different needle and syringe programmes settings or syringe dispensation policies on drug injecting behaviours, but mobile van sites and vending machines appeared to attract younger people who inject drugs and people who inject drugs with higher risk profiles. Two studies of interventions aimed at encouraging people who inject drugs to enter drug treatment reported limited effects, but one study found that the combination of methadone treatment and full participation in needle and syringe programmes was associated with a lower incidence of HIV and HCV. In addition, one study indicated that hospital-based programmes may improve access to health care services among people who inject drugs.  Currently, it is difficult to draw conclusions on 'what works best' within the range of harm reduction services available to people who inject drugs. Further studies are required which have a stated aim of evaluating how different approaches to the organisation and delivery needle and syringe programmes influence on effectiveness.

For abstract access click here:
http://www.ncbi.nlm.nih.gov/pubmed/20189375
Editors’ note: This systematic review of existing studies found a paucity of evidence on the impact of organising needle-syringe programmes in different ways. The majority of evaluated programmes had combined needle-syringe distribution with other harm reduction strategies such as outreach, distribution of materials, and testing for blood borne viruses. The settings in which the services were offered varied. However, it was not possible to determine the effects of the additional components nor of different settings on drug injecting behaviours and the incidence and prevalence of blood borne viruses due to  limitations in study design. The majority of studies were observational in nature and only four were randomised controlled trials. However, a variety of non-randomised designs for evaluation of public health interventions can be used to compare different service delivery models. It makes common sense that ‘one-stop shopping’ for HIV testing, needles/syringes, low threshold methadone, social support, and primary health care would best meet the needs of people who inject drugs. Key informant interviews, focus groups, and web surveys can be used to gather information on what service users think would most likely work for themselves and others. The principles of good participatory practice in biomedical HIV prevention trials of respect, transparency, integrity, and accountability are equally applicable to the design of services that will reduce risk and improve the health of people who inject drugs (cf UNAIDS/AVAC Good participatory practice guidelines in biomedical  HIV prevention trials: http://data.unaids.org/pub/manual/2007/jc1364_good_participatory_guidelines_en.pdf
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Injecting Drug Use

Flashblood: blood sharing among female injecting drug users in Tanzania.

McCurdy SA, Ross MW, Williams ML, Kilonzo GP, Leshabari MT. Addiction. 2010 Mar. [Epub ahead of print]

This study examined the association between the blood-sharing practice of 'flashblood' use and demographic factors, human immunodeficiency virus (HIV) status and variables associated with risky sex and drug behaviours among female injecting drug users. Flashblood is a syringe-full of blood passed from someone who has just injected heroin to someone else who injects it in lieu of heroin. In a cross-sectional study conducted in Dar es Salaam, Tanzania, one hundred and sixty-nine female injecting drug users were recruited using purposive sampling for hard-to-reach populations. The association between flashblood use, demographic and personal characteristics and risky sex and drug use variables was analyzed by t-test and chi (2) test. The association between flashblood use and residential neighbourhood was mapped. Flashblood users were more likely to: be married (P = 0.05), have lived in the current housing situation for a shorter time (P < 0.000), have been forced as a child to have sex by a family member (P = 0.007), inject heroin more in the  last 30 days (P = 0.005), smoke marijuana at an earlier age (P = 0.04), use contaminated rinse-water (P < 0.03), pool money for drugs (P < 0.03) and share drugs (P = 0.000). Non-flashblood users were more likely to live with their parents (P = 0.003). Neighbourhood flashblood use was highest near downtown and in the next two adjoining suburbs and lowest in the most distant suburbs. These data indicate that more vulnerable women who are heavy users and living in shorter-term housing are injecting flashblood. The practice of flashblood appears to be spreading from the inner city to the suburbs.

For abstract access click here:
http://www.ncbi.nlm.nih.gov/pubmed/20331567
Editors’ note:  The emergence of flashblood in 2005 in Tanzania coincided with increased policing of drug users’ activities and rising heroin prices. A survival strategy created by women who inject drugs to help each other, flashblood is an altruistic practice anchored in social networks of reciprocity and obligation in Tanzania. Both givers and users believe that withdrawal symptoms can be staved off by the heroin in the blood that the giver draws back into her syringe right after she has injected heroin. Understanding the basis of such sharing in a culture that places a high value on giving is helpful, but the risk environment is conditioned by even more powerful socioeconomic and political factors that led to Tanzania evolving from a transit site for drug trafficking to a country with an established local client base. Tanzania has no opiate substitution treatment and no needle-syringe programmes. In fact, the interrelationships between the social environment, repressive policies, and individual risk need to be acknowledged and then tackled with rights-based, evidence-informed public health policies and programmes to reduce risk for women, their communities, and the country as a whole. There are important lessons to be drawn from leadership here and in neighbouring countries that are also on drug trafficking routes.
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Injecting drug use

The Washington Needle Depot: fitting healthcare to injection drug users rather than injection drug users to healthcare: moving from a syringe exchange to syringe distribution model.

Small D, Glickman A, Rigter G, Walter T. Harm Reduct J. 2010 7:1.

Needle exchange programs chase political as well as epidemiological dragons, carrying within them both implicit moral and political goals. In the exchange model of syringe distribution, injection drug users must provide used needles in order to receive new needles. Distribution and retrieval are co-existent in the exchange model. Likewise, limitations on how many needles can be received at a time compel addicts to have multiple points of contact with professionals where the virtues of treatment and detox are impressed upon them. The centre of gravity for syringe distribution programs needs to shift from needle exchange to needle distribution, which provides unlimited access to syringes. This paper provides a case study of the Washington Needle Depot, a program operating under the syringe distribution model, showing that the distribution and retrieval of syringes can be separated with effective results. Further, the experience of injecting drug users is utilized, through paid employment, to provide a vulnerable population of people with clean syringes to prevent HIV and HCV.

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Editors’ note: Although NSP or needle-syringe programmes often began on an exchange basis as a means to achieve political buy-in, there are few that have remained so for a variety of reasons. These include the ineffectiveness of the exchange model or of needle quotas in controlling HIV epidemics driven in part by injecting cocaine, which has a short duration of action and tends to be injected frequently when it is being injected. More significantly, a shift in thinking about risk behaviour in general and injecting behaviour more specifically has led to a focus on the risk environment. With respect to people who inject drugs, multi-person use of injecting equipment is more likely when needles and syringes are in short supply. Calling this ‘needle sharing’ implies that this is a positive social behaviour rather than one determined primarily by the availability of equipment. For 9 years after the first needle syringe programmes in Canada opened in Vancouver and Montreal, the Olympic City used an exchange model. Whether this contributed to the extent of the HIV and hepatitis C epidemics in Vancouver today remains a question but since 2000 needle syringe distribution has been decentralised to health clinics, peer support groups, homeless shelters, non-profit agencies and housing providers. By the way, the ‘Washington’ in this article is not D.C., USA!
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IDU

Retention in Opioid Substitution Treatment: A Major Predictor of Long-Term Virological Success for HIV-Infected Injection Drug Users Receiving Antiretroviral Treatment.

Roux P, Carrieri MP, Cohen J, Ravaux I, Poizot-Martin I, Dellamonica P, Spire B. Clin Infect Dis. 2009; 49:1433-40.

The positive impact of opioid substitution treatment on opioid-dependent individuals with human immunodeficiency virus (HIV) infection is well documented, especially with regard to adherence to antiretroviral therapy. Roux et al used the data from a 5-year longitudinal study of the MANIF 2000 cohort of individuals infected with HIV (as a result of injection drug use) and receiving ART to investigate the predictors of long-term virological success. Data were collected every 6 months from outpatient hospital services delivering HIV care in France. The authors selected all patients who were receiving antiretroviral therapy for at least 6 months (baseline visit) and who had indications for opioid substitution treatment (ie, still dependent on opioids). They selected a total of 113 patients, accounting for a total of 562 visits for all the analyses. Long-term virological success was defined as an undetectable viral load after at least 6 months on antiretroviral therapy. Retention in opioid substitution treatment was defined as the time interval between the last initiation or reinitiation of opioid substitution treatment during antiretroviral therapy follow-up and any given visit on opioid substitution treatment. A mixed logistic model was used to identify predictors of long-term virological success. At baseline, 53 patients were receiving buprenorphine, 28 patients were receiving methadone, and 32 patients were not on opioid substitution treatment. The median duration of opioid substitution treatment was 25 months (range, 3-42 months). In the multivariate analysis, after adjustment for significant predictors of long-term virological success such as adherence to antiretroviral therapy and early virological response, retention in opioid substitution treatment was associated with long-term virological success (odds ratio, 1.20 per 6-month increase; 95% confidence interval, 1.09-1.32). The study presents important evidence of the positive impact of retention in opioid substitution treatment on HIV outcomes. Increasing access to opioid substitution treatment based on a comprehensive model of care for HIV-infected patients who have indications for opioid substitution treatment may foster adherence and ensure long-term response to antiretroviral therapy.

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Editors’ note: Although people who inject drugs and who adhere to antiretroviral treatment have similar HIV outcomes to people who do not inject drugs, physicians may deny or delay initiation of antiretroviral treatment to active drug users. This is the first study to show that retention in opioid substitution treatment contributes to long-term virological suppression in injecting drug users on antiretroviral treatment. Expanded access to opioid substitutes, in the context of comprehensive care, is known to reduce the use of nonsterile injecting equipment and to increase consistent condom use. Given that opioid substitutes are included in the WHO list of essential medicines, the virological outcomes reported here give added impetus to initiatives to increase access to opioid substitution treatment for people living with HIV who inject drugs.

 


 Expanding the reach of harm reduction in Thailand: Experiences with a drug user-run drop-in centre.

Kerr T, Hayashi K, Fairbairn N, Kaplan K, Suwannawong P, Zhang R, Wood E . Int J Drug Policy. 2009 Sep. [Epub ahead of print]

Despite an ongoing epidemic of HIV among Thai people who inject drugs, Thailand has failed to implement essential harm reduction programmes. In response, a drug user-led harm reduction centre opened in 2004 in an effort to expand reduction programming in Thailand. The authors examined experiences with the Mitsampan Harm Reduction Centre (MSHRC) among injecting drug users participating in the Mitsampan Community Research Project ( Bangkok). Multivariate logistic regression was used to identify factors associated with Mitsampan Harm Reduction Centre use. Kerr et al also examined services used at and barriers to the Mitsampan Harm Reduction Centre. 252 injecting drug users participated in this study, including 66 (26.2%) females. In total, 74 (29.3%) participants had accessed the Mitsampan Harm Reduction Centre. In multivariate analyses, Mitsampan Harm Reduction Centre use was positively associated with difficulty accessing syringes (Adjusted Odds Ratio [AOR]=4.05; 95% Confidence Interval [CI]: 1.67-9.80), midazolam injection (AOR=3.25; 95%CI: 1.58-6.71), having greater than primary school education (AOR=1.88; 95%CI: 1.01-3.52), and was negatively associated with female gender (AOR=0.20; 95%CI: 0.08-0.50). Forms of support most commonly accessed included: syringe distribution (100%), food and a place to rest (83.8%), HIV education (75.7%), and safer injecting education (66.2%). The primary reason given for not having accessed the Mitsampan Harm Reduction Centre was “didn’t know it existed.” The Mitsampan Harm Reduction Centre is expanding the scope of harm reduction in Thailand by reaching injecting drug users, including those who report difficulty accessing sterile syringes, and by providing various forms of support. In order to maximise its benefits, efforts should be made to increase awareness of the Mitsampan Harm Reduction Centre, in particular among women.

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Editors’ note: Although drug user-led initiatives to provide harm reduction services have been described in North America, Europe, and Australia, the group of drug users who opened this drug-user-run drop-in centre in Bangkok in 2004 with funding from the Global Fund to fight AIDS, Tuberculosis and Malaria were sailing in un-charted waters for Thailand. The Thai Drug Users Network and the Thai AIDS Treatment Action Group (TTAG) collaborated to start the centre which is open six days a week from 10 am to 7 pm and has 500 to 600 visits per month. At the end of the Global Fund grant in 2008, TTAG assumed oversight of the centre, with drug users continuing to run the centre. It is perhaps not surprising that many drug users interviewed were not aware of the centre given obvious difficulties in advertising its services in a context of documented extreme stigma and discrimination. Expanding the scope of this service and increasing the availability of harm reduction services in general in Thailand will require enlightened leadership in order to reduce the risk of HIV acquisition and transmission among Thais who inject drugs.

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National responses - injecting drug use

A situation update on HIV epidemics among people who inject drugs and national responses in South-East Asia Region.

Sharma M, Oppenheimer E, Saidel T, Loo V, Garg R. AIDS. 2009;23:1405-13.

The authors explore the magnitude of and current trends in HIV infection among people who inject drugs and estimate the reach of harm reduction interventions among them in seven high-burden countries of the South-East Asia Region. Their data are drawn from the published and unpublished literature, routine national HIV serological and behavioural surveillance surveys and information from key informants. Six countries ( Thailand, Myanmar, Nepal, Indonesia, India, and Bangladesh) had significant epidemics of HIV among people who inject drugs. In Thailand, Indonesia, Bangladesh, Myanmar and India, there is no significant decline in the prevalence of HIV epidemics in this population. In Nepal, north-east India, and some cities in Myanmar, there is some evidence of decline in risk behaviours and a concomitant decline in HIV prevalence. This is countered by the rapid emergence of epidemics in new geographical pockets. Available programme data suggest that less than 12 000 of the estimated 800 000 (1.5%) people who inject drugs have access to opioid substitution therapy, and 20-25% were reached by needle-syringe programmes at least once during the past 12 months. A mapping of harm reduction interventions suggests a lack of congruence between the location of established and emerging epidemics and the availability of scaled-up prevention services. Harm reduction interventions in closed settings are almost nonexistent. To achieve significant impact on the HIV epidemics among this population, governments, specifically national AIDS programmes, urgently need to scale up needle-syringe programmes and opioid substitution therapy and make these widely available both in community and closed settings.

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Editors’ note: This broad mapping, across 7 high drug use burden South East Asian countries with significant, longstanding HIV epidemics among people who inject drugs, draws from a variety of data sources to paint a picture of national prevention responses. In addition to the strikingly inadequate reach of harm reduction programmes, current surveillance systems are not designed to pick up new epidemics. Indonesia is the only country with a national strategy (2005-2009) to guide HIV prevention, treatment, and care in prison settings – the very settings that are known to be high-risk environments worldwide for HIV transmission. Methadone and buprenorphine are unavailable and too expensive in most countries. Tensions between supply/demand reduction and harm reduction approaches call out now for enlightened leadership at all levels to implement effective HIV prevention programmes to cover at least 50-60% of people who inject drugs.  

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Injecting drug use

A Literature Review of International Implementation of Opioid Substitution Treatment in Prisons: Equivalence of Care? Larney S, Dolan K. Eur Addict Res. 2009; 15: 107-12.

Opioid substitution treatment is an effective treatment for heroin dependence. The World Health Organization has recommended that opioid substitution treatment be implemented in prisons because of its role in reducing drug injection and associated problems such as HIV transmission. The aim of this paper was to examine the extent to which opioid substitution treatment has been implemented in prisons internationally. As of January 2008, opioid substitution treatment had been implemented in prisons in at least 29 countries or territories. For 20 of those countries, the proportion of all prisoners in opioid substitution treatment could be calculated, with results ranging from less than 1% to over 14%. At least 37 countries offer opioid substitution treatment in community settings, but not prisons. This study has identified an increase in the international implementation of opioid substitution treatment in prisons. However, there remain large numbers of prisoners who are unable to access opioid substitution treatment, even in countries that provide such programs. This raises issues of equivalence of care for prisoners and HIV prevention in prisons.

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Editors’ note: Opioid substitution therapy, the most cost-effective treatment available for heroin dependence, is available in 66 countries and territories, including low- and middle-income countries such as China, Indonesia, and Iran. The largest prison programmes are in Ireland, Scotland, and Spain with 12 to 14% of inmates in these countries receiving opioid substitution treatment. Some countries unnecessarily restrict access to inmates serving sentences of a particular length, to those who were in treatment before incarceration, or to those who can confirm that they have a post-release treatment place. Furthermore, the 37 countries which offer opioid substitution therapy in the community but not in prisons are contravening the multiple international covenants and legal instruments that entitle incarcerated people access to health services equivalent to those available in the general community in their countries. Thus, despite prison access to opioid substitution treatment having increased from 5 countries in 1996 to 29 in 2008, much remains to be done to improve coverage worldwide both in prisons and in the community.

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