It is widely recognized that injecting drug use plays a very important role in the HIV/AIDS epidemic, principally in Asia, Eastern Europe and the United States.23 In some countries, especially in Eastern Europe, and South East Asia, HIV infection primarily linked with drug use surpasses that linked to sexual transmission.
According to UNAIDS, injecting drug use is estimated to account for nearly one-third of new HIV infections outside sub-Saharan Africa, but less than 8 percent of injecting drug users are reached by HIV prevention services. Unfortunately, the scaling up of HIV prevention and -- even more so -- care and treatment for drug users is lagging behind in the overall AIDS response.24 Drug use is increasing in Africa, LAC, and other regions with related increases in HIV infection. Even where injecting drug use is declining in favor of other forms, high rates of unplanned sex with multiple partners continue to increase drug-related HIV.
Various studies from the United States and Europe have suggested that drug users are responsible for the majority of heterosexual transmission of HIV outside of Sub-Saharan Africa. Yet, while broad AIDS prevention campaigns have so far focused on sexual behavior and promotion of condom use, those interventions addressing drug users have been mainly focused on drug-injecting behavior.25 Consequently, these efforts have been able to reduce needle sharing but have failed to reduce risk-taking sexual behavior. Drug users continue to engage in unprotected sex even if they are aware of the risk of HIV transmission. This is particularly true in relation to steady sexual partners over casual sexual partners.
Illegal drug use is a social problem and should be dealt with as such. Excessive reliance on law enforcement and punishment is particularly counterproductive to decreasing high HIV transmission among IDU, as they are driven to hide, have no access to health services or information, and for other reasons stated above for SW and MSM.
Overall, injecting drug users belong to the most underserved group of civil society because of the high number of low-income people using illegal drugs in a more intensive and damaging manner. They are confronted with the illegality of their activities and stigmatizing attitudes, and those involved in severe drug consumption face great barriers to integrating socially and in the work world.
Factors such as poverty, limited opportunities, and repressive, punitive and discriminatory prevention policies increase the vulnerability of such groups to HIV/AIDS. Injecting drug use is increasingly common among sex workers, and that double risk warrants effective programming, addressing both risk factors with each group.
Situations that increase the vulnerability of IDU to HIV infection
� Sharing needles and syringes infected with the virus;
� Inadequate cleaning of needles and syringes belonging to different IDU kept in the same container can promote transmitting not only HIV, but also Hepatitis B and C;
� Unprotected and multiple-partner sexual practices that can accompany drug use, abusive alcohol consumption, and transmission to non-IDU partners;
� The legal framework adopted in the great majority of countries criminalizes drug use and contributes to sustained high levels of social stigma and discrimination against drug users, necessitating hiding, isolation, and moving underground;
� Lack of, or inadequate, HIV prevention messages specifically designed to address the very different needs and interests of IDU;
� Pathfinder�s VCT program in Moldova has seen difficulty with testing for IDU due to sensitive veins, or their not wanting blood to be drawn and not being considered a good bet for adherence. They are more likely to be passed up for ART and/or not provided additional needed support.
Effective HIV prevention strategies for IDU
Traditionally, three strategies have been adopted in the control of drug use, although only the last has proven effective for HIV prevention programming among IDU:
� Offer reduction: Actions by government and law enforcement to eradicate plantations, combat money laundering, stop drug shipments across and within borders, and generally try to reduce supply. However, the �War on Drugs� has not reduced the number of drug users, but has generated lots of crime, graft, official corruption, and driven drug users further underground.26
� Demand reduction: Actions to diminish drug initiation and consumption, and making treatment available to addicted users � to reduce demand for drugs, e.g., methadone maintenance programs.
� Harm reduction: Actions to prevent harmful consequences to the health of users and their partners, BEFORE offering treatment and other alternatives to drug use.
Harm reduction is based on the assumption that reducing harm to the health of drug users (HIV transmission, Hepatitis B and C, and death by overdose), their families and their communities is primary (first things first!) before attempting to stop the drug use. Harm reduction is not focused on stopping drug use, but how to use them safely. As mentioned before, social behavior is not easy to change, particularly when physical addiction is added into the mix. So preventing harm and infection should not wait until the behavior change has been completed. IDU should be able to access health services and information about HIV and other deadly infections openly and without fear and then be offered treatment and other social opportunities, as opposed to punishment, which drives people away from help and services.
One example: the Vietnam Government recently adopted a national policy of combined demand reduction and harm reduction, and made it a crime to harass IDU�s or sex workers who are trying to access preventive services.
Although the concept originated in England in 1926, it was in Holland, during the 1980s, that harm reduction interventions were effectively implemented by an association of drug users concerned with the high rates of hepatitis among IDU.27 As high rates of HIV prevalence among injecting drug users began to emerge in various countries, harm reduction became an important element in HIV prevention efforts as well.
Harm reduction is the most effective, (including cost-effective), approach to prevention of HIV/AIDS among drug users and has been widely and officially accepted across many countries, with notable exceptions (including the US). The strategy intends to reduce health damage in users who can not, do not want to, or are not able to stop using injecting drugs, and therefore share used needles and syringes and expose themselves to HIV/AIDS infection. The scope of harm reduction interventions is very broad and not only focused on the distribution or exchange of syringes and needles. In fact, harm reduction interventions can successfully be implemented with users of non-injecting drugs, like alcohol, marijuana, cocaine, crack cocaine, and others.
The intent of this approach is to minimize the preventable harm that can be inflicted with drug use, injecting or not. If drug users can access clean needles, or bleach to clean their needles and syringes without fear of imprisonment, then they can be reached with other services, including STI/HIV prevention, detoxification and/or drug substitutes.
In some countries, the cheaper and more addictive crack has replaced the use of injecting drugs. If risk of HIV infection through the sharing of syringes and needles has diminished in these settings, risk of infection through unprotected sex while high from drugs is still significant and should be addressed appropriately. Consequently, safer sex workshops are also of fundamental importance in reducing vulnerability of drug users to HIV infection and should be part of the role played by harm reduction agencies.
The selection and training of qualified harm reduction community and facility agents is made more difficult by additional requirements. Besides gaining proficient knowledge of issues related to HIV prevention, sexuality, drug addiction, and interpersonal communication, they need to enjoy the total acceptance and trust of the group they serve and be free of all signs of prejudice. Additionally, they need to be trained in special skills on how to deal with dangerous, sometimes life-threatening situations, like police raids and intimidation from local drug dealers. Successful harm reduction programs have made use of ex-IDU as peer educators.
Promoting Harm Reduction: Harm reduction interventions can work more effectively if concomitant use is made of the following activities:
Provision of information on how HIV is transmitted through sharing of injecting equipment or relaxing safer sex practices while intoxicated;
Provision of free sterile injecting equipment, or needle exchange, and condoms;
Bleach distribution programs.
The role of advocacy and social mobilization
As reported by UNAIDS, effective strategies to address HIV prevention among IDU are highly controversial in many countries. Thus, it is essential that interventions aiming at successful results include substantial efforts to overcome community fears and government concerns about the proposed initiatives. This can be achieved through well-designed advocacy and social mobilization interventions at various levels. Normally, it is useful to initiate those at the community where prevention interventions will be carried out, through formal and informal meetings, public information campaigns, involvement by programme managers in multisectoral AIDS and drugs committees and, in most cases, by carefully building relationships with selected representatives from the mass media.
Pathfinder�s experience in Brazil, working in collaboration with the Centro de Estudos e Terapia do Abuso de Drogas (CETAD) in Salvador, has shown the importance of addressing needs and interests of the whole neighborhood rather than just drug users individually. The adopted approach strengthened a wide range of services that, once established, provided a comprehensive set of drug and HIV-prevention activities as well as general health and social assistance. While the main objective was to provide services to injecting drug users, crack smokers and other non-injecting drug users, services also reached out to their families, sexual partners, neighbors and other people living in drug-using neighborhoods to increase understanding of drug users and increase social integration to support risk reduction.
In addition, the following interventions can enhance impact of HIV prevention among drug users:28 29
� Programs of peer educators, educated on all issues of STI and HIV transmission associated with injecting and other drug use/abuse. Peer educators should work in all places where IDU gather and live.
� Inviting IDU and ex-IDU into community development activities, and into planning and delivery of health services for IDU, so they become part of the solution and insert their perspective on the real problems and how to resolve them.
� Training health providers to root out stigma and provide confidential space for drug users to discuss their real health issues, so their vulnerability can be effectively addressed.
� Social mobilization activities, like soccer tournaments and music workshops, provide opportunities for a closer interaction between drug users and the population living in the same neighborhoods, greatly contributing to the reduction of social prejudice and stigma.
� Organization of meetings with parents and spouses of drug users to discuss issues like addiction, HIV/AIDS prevention, care, treatment, and support.
� Demand and develop drug treatment programs with no waiting time or cost barriers, and follow programs to support reintegration and act as safety nets.
� Involve local community health workers/agents in harm reduction strategies, which promote confidence among drug users to seek care at local health facilities.
� Make referrals to specialized medical, psychological and legal services, (with no fear of reprisals) and, if possible, providing support for transportation.
� Given the reluctance of drug users to seek services at specific facilities, the use of mobile harm reduction services can be highly effective in providing IEC messages and preventions commodities (condoms, syringes and needles) at the community level.
� Sensitization meetings with police to curb unnecessary violence towards drug users and the community where they live or gather.
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