Introduction

Drug dependence is a complex, chronic, relapsing condition that is often accompanied by severe health, psychological, economic, legal, and social consequences (IOM, 1990, 1995). It is manifested by a complex set of behaviors including compulsive drug craving, seeking, and use that interferes with an individual’s physical, mental, and social functioning (IOM, 1997; McLellan et al., 2000). Similar to other chronic conditions, such as heart disease or diabetes, individuals with drug dependence can stabilize their condition by making behavioral changes and with the use of appropriate medications (WHO et al., 2004). Drug-dependent individuals have high rates of medical and psychiatric comorbidity and increased risk of premature mortality (DHHS, 2006). Injecting drug users are particularly vulnerable to HIV and other bloodborne infections (such as hepatitis C) as a result of sharing contaminated injecting equipment. All drug-dependent individuals, including injecting drug users (IDUs), may be at increased risk of HIV infection because of high-risk sexual behaviors.

There are an estimated 13.2 million injecting drug users (IDUs) worldwide—78 percent of whom live in developing or transitional countries (Aceijas et al., 2004). The sharing of contaminated injecting equipment1 has become a major driving force of the global AIDS epidemic and is the primary mode of HIV transmission in many countries throughout Eastern

1

Injecting equipment may include needles, syringes, cookers, cotton, and water.



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Introduction Drug dependence is a complex, chronic, relapsing condition that is often accompanied by severe health, psychological, economic, legal, and social consequences (IOM, 1990, 1995). It is manifested by a complex set of behaviors including compulsive drug craving, seeking, and use that interferes with an individual’s physical, mental, and social functioning (IOM, 1997; McLellan et al., 2000). Similar to other chronic conditions, such as heart disease or diabetes, individuals with drug dependence can stabilize their condition by making behavioral changes and with the use of appropriate medications (WHO et al., 2004). Drug-dependent individuals have high rates of medical and psychiatric comorbidity and increased risk of premature mortality (DHHS, 2006). Injecting drug users are particularly vulnerable to HIV and other bloodborne infections (such as hepatitis C) as a result of sharing contaminated injecting equipment. All drug-dependent individuals, including injecting drug users (IDUs), may be at increased risk of HIV infection because of high-risk sexual behaviors. There are an estimated 13.2 million injecting drug users (IDUs) worldwide—78 percent of whom live in developing or transitional countries (Aceijas et al., 2004). The sharing of contaminated injecting equipment1 has become a major driving force of the global AIDS epidemic and is the primary mode of HIV transmission in many countries throughout Eastern 1 Injecting equipment may include needles, syringes, cookers, cotton, and water.

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Europe, the Commonwealth of Independent States,2 and significant parts of Asia (UNAIDS, 2006). In some cases, epidemics initially fueled by the sharing of contaminated injecting equipment are spreading through sexual transmission from IDUs to non-injecting populations, and through perinatal transmission to newborns. Reversing the rise of HIV infections among IDUs has thus become an urgent global public health challenge—one that remains largely unmet. STUDY GOALS AND APPROACH In response to this challenge, in 2005 the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Bill & Melinda Gates Foundation commissioned the Institute of Medicine to undertake an expedited review of the scientific evidence on the effectiveness of strategies to prevent HIV transmission through contaminated injecting equipment, with a specific focus on countries throughout Eastern Europe, the Commonwealth of Independent States, and significant parts of Asia, where injecting drug use is a primary driver of the HIV/AIDS epidemic. In this report, such countries are labeled as “high-risk,” indicating that injecting drug use is, or is on the verge of becoming, the primary driver of the HIV epidemic. The charge to the Committee included five questions. They are listed here in the order in which they are addressed in the chapters. The Committee found it most helpful to first discuss the evidence on the intermediate outcomes of drug-related risk (question one) and sex-related risk (question two) prior to examining the impact on HIV transmission (question three). What impact do needle and syringe exchange, disinfection programs, drug substitution programs, drug treatment programs, and counseling and education have on the extent and frequency of drug injection? What evidence is there on the extent to which these prevention strategies help reduce HIV transmission from IDUs to their sex partners and through maternal-to-child transmission to their offspring? How effective are such programs in reducing HIV transmission among IDUs? To what extent do such programs also increase the use of health and social services and drug treatment? What evidence is there that programs aimed at reducing the risk of HIV transmission among IDUs are more effective when they are part of a 2 The Commonwealth of Independent States includes Azerbaijan, Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, Tajikistan, Turkmenistan, Uzbekistan, and Ukraine.

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comprehensive array of services, which include outreach, HIV prevention education, counseling, referral to drug substitution treatment, drug rehabilitation services, and medical and psychosocial support? In response to this charge, the Committee convened a public workshop in Geneva in December 2005 to gather information from experts on IDU-driven HIV epidemics in the most affected regions of the world, including Eastern Europe, the Commonwealth of Independent States, and significant parts of Asia. Experts from other regions also provided information on their experiences in preventing HIV infection among IDUs (see Appendix A for the agenda of this meeting). The Committee further conducted a comprehensive search of the English language peer-reviewed scientific literature, and evaluated previous systematic reviews and reports on these issues (see Appendix B for an overview of the Committee’s literature searches and review methods). While the Committee sought evidence from high-risk countries, the literature review and evaluation included evidence from all over the world. In reviewing the evidence, the Committee grouped the range of HIV prevention strategies for IDUs it was asked to address in the charge into three categories: (1) drug dependence treatment programs, which include both pharmacotherapies and psychosocial interventions; (2) sterile needle and syringe access programs; and (3) outreach and education programs (see Chapter 1 for descriptions of these interventions). The Committee then assessed the evidence it had gathered at a closed meeting in Washington, DC, in March 2006, and during later conference calls. This report focuses on programs that are designed to prevent the transmission of HIV among injecting drug users. These programs range from efforts to curtail non-medical drug use to those that encourage reduction in high-risk behavior among drug users. The term “harm reduction” is often used to describe programs such as sterile needle and syringe access because their primary aim is to reduce the harms related to drug use among those who are unable or unwilling to stop using drugs. However, because the term has a wide range of interpretations, the Committee refers to all interventions in this report as HIV prevention programs for IDUs. Several issues are beyond the Committee’s charge and are not addressed in this report. First, the committee did not evaluate various drug control policies, such as supply and demand reduction strategies. While a large number of drug users interface with the criminal justice system, the committee did not evaluate the impact of criminal justice programs on drug use, HIV risk behaviors, or HIV transmission. An evaluation of programs such as mandatory drug treatment or diversion of drug users from the criminal justice system into treatment settings was also outside the scope of this study. Similarly, the committee did not evaluate interventions

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for primary prevention of drug use, although it believes such approaches are an important complement to strategies to prevent HIV infection among drug users. In addition, the committee did not examine strategies to prevent non-injecting drug users from becoming IDUs. There are a variety of HIV prevention and treatment programs which, although they apply to IDUs, are not specific to this population. These interventions, such as voluntary counseling and testing, antiretroviral therapy, and prevention and treatment of sexually transmitted infections, target broader populations. While there is a large body of evidence evaluating the effectiveness and efficacy of these interventions, the Committee’s review was limited to those interventions specific to IDUs. Therefore, only a brief overview of these broader interventions is presented in Chapter 1. Certain interventions that specifically target drug-related risk behavior, such as sterile needle and syringe access programs or medications for opioid dependence, would not be expected to decrease sex-related risk behavior, unless sexual risk reduction education or provision of condoms were a component of the program—a fact that studies do not generally reveal. Many communities attempting to address injecting drug use have independent programs to educate the broader population about HIV, reduce high-risk sexual exposures, and enhance condom use for various high-risk populations. While the Committee considered the impact of the specific HIV prevention programs for IDUs that were included in its charge on sex-related risk behavior, an evaluation of the applicability and effectiveness on IDUs of sex-related risk reduction programs at the population level not specifically focused on IDUs was beyond the scope of this report. Because this report focuses on HIV prevention, it considers but does not fully evaluate strategies for preventing the transmission of other bloodborne infections through contaminated injecting equipment, such as hepatitis C. Furthermore, the Committee does not evaluate prevention strategies to reduce nosocomial HIV infections acquired from injecting equipment used in medical settings (e.g., through reuse of contaminated needles and syringes or accidental needle sticks resulting from improper disposal of needles and other sharps). Finally, although the report focuses on HIV prevention for IDUs in high-risk countries, the Committee considered evidence from countries around the world. The findings and recommendations of this report are also applicable to countries where injecting drug use is not the primary driver, but in which injection drug use is nevertheless associated with significant HIV transmission.

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ORGANIZATION OF THE REPORT Chapter 1 reviews the epidemiology of HIV among IDUs, and discusses factors affecting HIV-related risks among IDUs. It also outlines major HIV prevention strategies for IDUs and their coverage. Chapters 2 and 3 provide the Committee’s evaluation, conclusions, and recommendations on the major HIV prevention strategies highlighted in the charge. Chapter 2 reviews HIV prevention strategies that are part of treatment for drug dependence, including both pharmacotherapies and psychosocial interventions. Chapter 3 reviews evidence regarding sterile needle and syringe access programs, and outreach and education efforts. Chapter 4 summarizes the Committee’s findings and highlights the importance of the local context—such as political, legal, and economic dimensions—in policy decisions, and provides recommendations that policymakers should consider when deciding which prevention programs to implement. Several appendixes provide additional information on the following: the agenda of the Committee’s December 2005 information-gathering meeting (Appendix A); methods used in the Committee’s literature searches and review (Appendix B); case studies of HIV prevention for IDUs in select high-risk countries (Appendix C); summary of studies related to multi-component HIV prevention programs that include needle and syringe exchange (Appendix D); additional thoughts on a community randomized trial of multi-component HIV prevention programs (Appendix E); and committee member biographies (Appendix F). REFERENCES Aceijas C, Stimson G, Hickman M, Rhodes T. 2004. Global overview of injecting drug use and HIV infection among injecting drug users. AIDS. 18:2295–2303. DHHS (U.S. Department of Health and Human Services). 2006. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. [Online]. Available: http://aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf [accessed August 3, 2006]. IOM (Institute of Medicine). 1990. Treating Drug Problems: Volume 1. Washington, DC: National Academy Press. IOM. 1995. Federal Regulation of Methadone Treatment. Washington, DC: National Academy Press. IOM. 1997. Dispelling the Myths About Addiction. Washington, DC: National Academy Press. McLellan T, Lewis D, O’Brien C, Kleber H. 2000. Drug dependence, a chronic mental illness: Implications for treatment, insurance, and outcomes evaluation. Journal of the American Medical Association. 284(13):1689–1695. UNAIDS (Joint United Nations Programme on HIV/AIDS). 2006. 2006 Report on the Global AIDS Epidemic: A UNAIDS 10th Anniversary Special Edition. Geneva, Switzerland: UNAIDS. WHO (World Health Organization), United Nations Office on Drugs and Crime, UNAIDS. 2004. Substitution Maintenance Therapy in the Management of Opioid Dependence and HIV/AIDS Prevention: Position Paper. Geneva, Switzerland: WHO.

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