Turning to AIDS' Other Victims

In the decades since AIDS first emerged as a global public health threat, the gains have been substantial in fighting the epidemic in the general population, as well as in specific groups—gay men, blood transfusion recipients and infants with HIV-infected mothers who breastfeed.

And over the past decade, the African AIDS epidemic, embodied in the faces of orphans and women infected by their partners, has galvanized governments, private donors and international health agencies into action.

But another population ravaged by AIDS—people who use drugs—has attracted comparably little attention, even in regions where drug-related HIV is a major contributor to sharply rising infection rates. The epidemic is most pronounced in people who inject drugs, but sexual risk behaviors associated with other drugs are also an important factor in the HIV epidemic in drug users.

“This is a critical population that has been neglected for too long,” says Epidemiology professor Chris Beyrer, MD, MPH ’90, who accepted an invitation from The Lancet to serve as guest editor for the journal’s special series on HIV in drug users. “If we are serious about responding to the global AIDS pandemic and if we ignore this component, we will fail.”

The themed issue was unveiled in July at the 2010 International AIDS Society (IAS) Conference, held in Vienna, in part, to highlight the growing AIDS epidemics in Eastern Europe, fueled largely by injection drug use.“If you look at the rest of the world minus Africa, HIV related to drug use goes from being about 10 percent of the epidemic to a third of all infections,” Beyrer says.

Only 10 percent of injection drug users worldwide are being reached with a basic package of cost-effective prevention and treatment services, including needle and syringe exchange programs (NSP) and opioid substitution therapy (OST) for heroin users—strategies that have been shown to control outbreaks of HIV infection in this population—and antiretroviral drugs (ARV) for people who are HIV-positive. HIV experts point to discrimination against drug users, inadequate drug treatment and abusive law enforcement practices as key factors in the spreading drug-driven HIV epidemic and in the higher morbidity and mortality outcomes among HIV-infected drug users compared to others living with HIV.

The crisis is particularly acute in Eastern Europe and Asia, with five countries—China, Vietnam, Russia, Ukraine and Malaysia— accounting for an estimated 2.4 million cases of HIV and nearly half of all injection drug users living with HIV worldwide.

In many of the former Soviet countries, hard-hit by cases of drug-driven HIV, methadone is banned, making OST unavailable. The consequences of such gaps extend beyond the drug user. Recent research indicates that HIV transmission from male injection drug users to female sex partners seems to account for much of the rise of HIV infections in women in Russia. In 2007, women accounted for about 40 percent of new HIV cases in Russia and the Ukraine.

“It’s a legacy of the old Soviet system, which was opposed to methadone and made it illegal,” Beyrer says. “It should not be surprising that this is the region with the most severe problem with injection drug use.”

Frequently, in areas with high rates of drug-related HIV infection, drug treatment programs are of poor quality, and, in some cases, the alleged programs are actually labor camps.

An article in The Lancet series features the first-person account of a heroin addict in China who was involuntarily committed to a detoxification center. He writes that he received no medicine during the process, and no food or water in the first phase of treatment. After he was deemed “cured,” the man was assigned to a hard labor camp for a year.

“These are not people who have been convicted of trafficking in narcotics,” says Beyrer, director of the School’s Center for Public Health and Human Rights. “They may have failed a drug test of dubious quality, and now they’re suddenly in this locked factory environment facing torture, beatings and exposure to TB and HIV.”

One of the most important findings to emerge from the special edition, says Beyrer, is that while single interventions will yield only modest reductions in HIV transmission through injection drug use, a combination, high-coverage approach of NSP, OST and ARV could reduce the incidence of HIV infection by more than 50 percent.

“We actually have a toolkit in hand,” he says, “and if we brought it to bear, we could turn this around.”