Needle-syringe programmes and treatment will dramatically reduce HIV epidemic among people who inject drugs in Russia and Ukraine

Reducing HIV infection in people who inject drugs is impossible without targeting recently-infected subjects.

Vasylyeva TI, Friedman SR, Lourenco J, Gupta S, Hatzakis A, Pybus OG, Katzourakis A, Smyrnov P, Karamitros T, Paraskevis D, Magiorkinis G. AIDS. 2016 Nov 28;30(18):2885-2890.

Objective: Although our understanding of viral transmission among people who inject drugs (PWID) has improved, we still know little about when and how many times each injector transmits HIV throughout the duration of infection. We describe HIV dynamics in PWID to evaluate which preventive strategies can be efficient.

Design: Due to the notably scarce interventions, HIV-1 spread explosively in Russia and Ukraine in 1990s. By studying this epidemic between 1995 and 2005, we characterized naturally occurring transmission dynamics of HIV among PWID.

Method: We combined publicly available HIV pol and env sequences with prevalence estimates from Russia and Ukraine under an evolutionary epidemiology framework to characterize HIV transmissibility between PWID. We then constructed compartmental models to simulate HIV spread among PWID.

Results: In the absence of interventions, each injector transmits on average to 10 others. Half of the transmissions take place within 1 month after primary infection, suggesting that the epidemic will expand even after blocking all the post-first month transmissions. Primary prevention can realistically target the first month of infection, and we show that it is very efficient to control the spread of HIV-1 in PWID. Treating acutely infected on top of primary prevention is notably effective.

Conclusion: As a large proportion of transmissions among PWID occur within 1 month after infection, reducing and delaying transmissions through scale-up of harm reduction programmes should always form the backbone of HIV control strategies in PWID. Growing PWID populations in the developing world, where primary prevention is scarce, constitutes a public health time bomb

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Editor’s notes: This paper presents powerful findings from a mathematical model that sought to estimate how much prevalence of HIV will increase among people who inject drugs in 10-20 years’ time in the absence of HIV treatment and needle-syringe programmes. Findings suggest HIV prevalence will reach 86% in 20 years in the absence of programmes. The paper provides important new information to the growing body of evidence that estimates the impact of needle-syringe programmes and opioid substitution therapy in reducing HIV transmission among people who inject drugs, in the region. The authors focus on the impact of needle-syringe programmes and of the prevention benefits of treatment, reducing transmission among individuals recently acquiring HIV where infectivity is higher in the first month of infection. The estimates provide projections of programme impact in the realities of the current policy environment, given the prohibition of opioid substitution therapy in the Russian Federation. The model focusses on injection transmission routes only and does not consider sexual transmission among people who inject drugs. Therefore, projected estimates of HIV are likely to be underestimates. The paper is important in highlighting the urgent need for needle-syringe programmes and treatment among people who inject drugs in the region and highlighting the crisis in relation to HIV among people who inject drugs in Russia and Ukraine. Modelling estimates such as these are powerful tools to persuade policy makers of the urgent need for programmes.  Importantly the authors recognize the need for structural programmes. They highlight the need to create an enabling environment in which needle-syringe programmes can operate. This environment needs to include supportive policing practices and reducing stigma. 

Europe
Russian Federation, Ukraine
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