Health Action AIDS

Pandemic in Eurasia

The HIV/AIDS pandemic is growing rapidly in Eastern Europe and parts of Asia and the Middle East. Injection drug use is driving its' spread.

What is Necessary to Reverse the Spread of HIV/AIDS:

• While national attention over the last three years has focused on sexually transmitted HIV/AIDS in Southern Africa, the pandemic has grown exponentially among populations in Eastern Europe and the Former Soviet Union, Central Asia, Iran, as well as East Asia, China and Southeast Asia where it is largely driven by unsafe injection practices among heroin users. An estimated 30% of all HIV infections outside of sub-Saharan Africa are attributed to injection drug use. (1)

• The number of people with HIV in Eastern Europe and Central Asia is estimated at 1.6 million, almost a twenty-fold increase in less than ten years. In all of Asia, an estimated 8.3 million people are infected with HIV, and 1.1 million were newly infected in the past year. (2)

• In all these regions, rapidly expanding injecting drug use in the wake of economic and political disruption and increased heroin trafficking is driving HIV epidemics. According to UNAIDS, injection drug use accounts for 80% of all HIV cases in Eastern Europe and Central Asia. (3) There are similar trends in other parts of Asia. For example, in Vietnam the number of people living with HIV doubled from 2000 to 2005, as the numbers of heroin injectors dramatically increased. (4) Official estimates are that 260,000 people in Vietnam were living with HIV in 2005, and 57% of HIV cases were among injecting drug users.(5)

• The collapse of the Soviet Union, wars in Afghanistan, and decades of military dictatorship in Burma have all contributed to high rates of unemployment, lack of opportunity, and drug-dependent economies. The Bush administration admits that heroin trafficking will only increase in the near future, hence assuring increased risk of addiction, needle sharing, and HIV for many thousands. (6)

• Needle sharing is a highly efficient form of HIV transmission, and has led to explosive epidemics throughout these regions. Studies in cities around the world have shown that without adequate prevention, HIV prevalence can rise among drug users to as high as 40-90% infection rates within a period of months to only a few years. (7)

• In many of these countries, HIV infection via drug injection occurs mainly among young, economically marginalized and sexually active males. In Russia, for example, more than 80% of such cases are in persons under age 30. The result is that HIV spreads sexually beyond drug user networks, infecting women and reaching points where it can lead to generalized epidemics. (8)

• In Russia, the number of infected women has grown quickly in recent years. In 2003 33% of newly diagnosed HIV infections were in women, up from 24% in 2001. In the first nine months of 2004, 9,651 children were born to HIV positive mothers, compared to 2,777 in 2002. Between 15-20% of these children were HIV positive. (9)

• Preventing generalized epidemics in many countries is still possible, but the timing and scale of HIV prevention is crucial to success. There is an urgent need for HIV prevention for drug injectors on a large scale and at national levels. In countries such as Russia, where the epidemic has already spread beyond initial infected groups, the need for scaled up HIV/AIDS treatment and comprehensive HIV prevention has become an emergency. (10)

HIV prevention strategies for injection drug users are straightforward, and their effectiveness is well established. Extensive research has also confirmed that they are cost-effective and do not increase drug use.

• During more than two decades, a large number of studies have established the efficacy of HIV prevention interventions among drug injectors. The following interventions make up the core of a comprehensive approach: 1) improved access to sterile syringes; 2) accessible addiction treatment (particularly opiate substitution therapy); and 3) outreach and risk reduction education. Promotion of sexual risk reduction and condom use is also an essential part of HIV prevention among drug users. To prevent, control or reverse HIV/AIDS epidemics, all play essential roles.

• One review of data from 81 cities in Europe, Asia, and North America with and without needle exchange programs (one type of syringe access program) found that 52 cities without such programs had, on average, almost 6% increases of HIV prevalence per year. In contrast, in the 29 cities with syringe exchange programs HIV prevalence decreased by almost as much per year (5.8%). The average annual change in HIV prevalence per year was 11% lower in the cities with needle exchange programs (11).

• Research has established that needle exchange programs do not increase drug use, negatively impact addiction treatment, or increase the amount of injecting equipment on the street. According to the World Health Organization, “[t]here is no convincing evidence of major unintended negative consequences of programmes providing sterile injecting equipment to injecting drug users, such as initiation of injection among people who have not injected previously, or an increase in duration or frequency of illicit drug use or drug injection.” (12)

• Official resolutions in support of HIV prevention programs for injection drug users have been issued by the mainstream US medical, nursing and public health community, including the American Academy of Pediatrics, the American Medical Association, the American Nurses Association, The American Psychiatric Association, the American Pharmaceutical Association, the American Public Health Association, the American Society of Addiction Medicine, the Institute of Medicine, the National Association of Boards of Pharmacy, and others. (13)

The US Government has not promoted comprehensive, evidence-based, HIV prevention for injection drug users.

• The President's Emergency Plan for AIDS Relief (PEPFAR) has led to HIV/AIDS treatment and prevention for thousands in some of the most heavily AIDS-burdened countries, primarily in Africa. In addition, the US Agency for International Development (USAID) funds a number of interventions aimed at HIV prevention among injecting drug users in China, Vietnam, Burma, India, Pakistan, Nepal, Indonesia, and the Philippines. These programs are important and should be expanded, given the rapid spread of the pandemic through injection drug use.

• However, even though injection drug use is a driving force in the global pandemic, the US does not fund or promote programs that improve access to sterile syringes (such as needle/syringe exchange programs) – an absolutely critical means of preventing the spread of HIV/AIDS through injection drug use. Also important is promotion and funding of large-scale addiction treatment, especially opiate substitution therapy.

• Additionally, in March of 2006, the Office of US Global AIDS Coordinator issued a policy Guidance for HIV Prevention among Drug Injectors for PEPFAR. While the Guidance does highlight the importance of risk reduction, counseling, and addiction treatment as HIV prevention methods, it emphasizes secondary prevention for drug injectors already infected with HIV. The Guidance does not prioritize HIV prevention for uninfected drug injectors, nor does it clearly promote comprehensive evidence-based prevention strategies. (14) Notably absent is promotion of scaled-up opiate substitution addiction treatment therapy for uninfected heroin injectors, and acknowledgment of the essential role of access to sterile injecting equipment for HIV prevention.

The US Government can make a difference by promoting comprehensive evidence-based HIV prevention in official documents and increasing multilateral efforts through the Global Fund.

• The US Government is an influential source of technical expertise and funding for HIV prevention and treatment globally.

Urgent Recommendations to the US Government:

• The US Government should develop a science-based strategy that can contain and reverse injection drug-led HIV epidemics. Such a strategy does not currently exist in any coherent or comprehensive way. US global AIDS policies and programs should be consistent with such a strategy.

• The US government, its authorized agents and its grantees, must consistently provide accurate information about all evidence-based essential interventions and best practices in HIV-prevention for injection drug users. Such information should be clearly presented in all official, public venues, including in conferences, through guidance documents, and on websites.

• All such US documents and websites should promote primary prevention among drug users who are not yet infected, in addition to promoting prevention of transmission among or from HIV infected drug injectors to others.

• Essential evidence-based interventions and best practices for this population include the following: 1) access to sterile syringes, and specifically needle and syringe exchange programs, as among the most scientifically established effective interventions for this population; 2) accessible, effective addiction treatment (for opiate dependence, substitution therapy with methadone or buprenorphine); 3) outreach and risk reduction education, and promotion of sexual risk reduction and condom use.

• The US Government should support rapid expansion of HIV prevention programs among injection drug users, and place no constraints on US-funded programs' ability to collaborate with needle-exchange programs funded by other donors.

• The US Government should also encourage and support multilateral efforts (such as the Global Fund to Fight AIDS, Tuberculosis and Malaria) for prevention activities among drug users, with no constraints on funding HIV prevention methods that have been proven effective. This should be an urgent priority in countries where epidemics are driven by injection drug use, as in the regions highlighted here.

Timely access for drug injectors to the best available public health information and interventions is a human right. Article 12 of the 1966 International Covenant on Economic, Social and Cultural Rights, ratified by the UN, affirms “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health….” In the Declaration of Commitment, unanimously accepted at the 26th UN General Assembly Special Session on HIV/AIDS (UNGASS), 2001 (15) and reaffirmed in the UNGASS Declaration of Commitment in 2006, states made specific commitments relevant to people who inject drugs, including “expanded access to essential commodities, including male and female condoms and sterile injecting equipment.”

For more information, please contact Physicians for Human Rights at 617-301-4200 or 202-728-5355.

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