Injecting drug use

HIV treatment as prevention among injection drug users

Wood E, Milloy MJ, Montaner JS. Curr Opin HIV AIDS. 2012 Mar;7(2):151-6

The use of highly active antiretroviral therapy as a strategy to prevent the transmission of HIV infection is of substantial international interest. People who inject drugs are an important population with respect to HIV treatment as prevention because they are often less likely to access antiretroviral therapy in comparison with other risk groups. A recent multicentre randomized clinical trial demonstrated a 96% reduction in HIV transmission among heterosexual serodiscordant couples prescribed early antiretroviral therapy. Consistent with these results, independent observational studies from Baltimore and Vancouver have demonstrated that population level rates of antiretroviral therapy use among people who inject drugs are associated with reduced rates of HIV incidence. In addition, impact assessments of antiretroviral therapy delivery to people who inject drugs have generally demonstrated no negative effects of antiretroviral therapy use on rates of unsafe sex or unsafe needle/syringe use. Antiretroviral therapy prevents HIV transmission because it dramatically decreases HIV-1 RNA levels in biological fluids. This is relevant to vertical and sexual HIV transmission and also to blood-borne HIV transmission, as it is often the case among people who inject drugs. Efforts to expand antiretroviral therapy to people who inject drugs should be redoubled in an effort to realize both the individual and public health benefits of antiretroviral therapy.

For abstract access click here.  [2]

Editor’s note: This article reviews the ecological data on reduced ‘community viral load’ associated with antiretroviral treatment scale-up among people who inject drugs. It then makes the case for treatment initiation among people who inject drugs as soon as their HIV infection is detected to reap both individual and population-level benefits. Antiretroviral treatment does not increase the likelihood of unsafe needle/syringe use and it may or may not increase the risk of sexual risk behaviour (studies have produced conflicting results). A meta-analysis has shown that people who inject drugs who are started on antiretroviral treatment are not more likely to develop drug resistance. Finally, harms associated with injecting drugs, such as endocarditis, cellulitis and drug overdose, may bring people who inject drugs into contact with health care providers early in their HIV infection, providing an opportunity for HIV testing and early initiation of antiretroviral treatment. The biggest barrier to scaling up treatment access for people who inject drugs is their stigmatization and criminalisation – these will keep them away from health services and away from the benefits of antiretroviral therapy for themselves, their sexual and injecting partners, and the community.

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