Twenty years later
by Peter Piot
Executive Director, UNAIDS

The world has been responding to HIV/AIDS for twenty years, and some universal lessons have been learned during that period. One is that effective AIDS responses have to start with the world as it is, not as we would like it to be. A second lesson is that blaming or castigating people at risk of HIV infection simply adds to the stigma, drives risky behaviour underground and fails to stop the spread of the epidemic. And a third lesson is that no matter how well-hidden it may be, HIV transmission via injecting drug use has been at least partly responsible for the epidemic nearly everywhere.

Up to now, 114 countries have reported the occurrence of HIV infection among their drug injecting communities. Injecting drug use is either the main mode of transmission of HIV infection or one of the main modes in many countries in Asia, Latin America, Europe, and North America. Even in the epidemic in sub-Saharan Africa, although the great bulk of HIV transmission is attributable to sex, injecting drug use is also a source of risk. Since sharing injecting equipment causes a great deal Of contamination, this practice can be responsible for the unpredictable mushrooming of the epidemic. But the spread of HIV as the result of injecting drug use is never confined to the injecting drug users alone: injecting drug users also have sexual partners, and may also be mothers needing to protect their infants from HIV, and in many places the sex trade and drug abuse are closely associated. HIV transmission via injecting drug use therefore has the potential to kick-start much wider epidemics, such as that which occurred at the end of the 1980s in Thailand.

Halting the HIV epidemic wherever it is being driven by injecting drug use requires a three-fold strategy.

First, drug abuse* itself needs to prevented. Young people in particular need to be given priority in the prevention of drug abuse.

Secondly, access to drug abuse treatment should be facilitated, both because treatment helps to improve the quality of life of those with a history of drug abuse, and because health services provide an opportunity to pass on the message about HIV prevention and care.

Thirdly, effective outreach strategies should be implemented to engage drug users in HIV prevention strategies protecting them and their partners and families from exposure to HIV, and encouraging the uptake of substitutive treatment and medical care.

One of the main problems involved in responding to an epidemic fuelled by illicit behaviour is that of social exclusion. Not only does social exclusion make people more susceptible to HIV infection, but it also makes them harder to reach.

Finding effective responses to the problem of HIV among drug users means understanding the views of drug users, their cultural habits and those of the communities they live in and encouraging them to participate in designing solutions that work for them. Programmes need to be based on solid reality and they must be meaningful to the people they are designed to reach. Street-based and other innovative outreach activities make it possible to reach untreated drug injectors, increase the number of people undergoing drug treatment, and possibly reduce illicit drug-related risk behaviour and sexual risk behaviour as well as the incidence of HIV infection.

Several studies on the effectiveness of syringe and needle exchange programmes have shown that they do reduce both needle risk behaviour and the rate of HIV transmission, and no evidence has been found that they may encourage injecting drug use or increase any other public health risks in the communities served. These programmes also provide points of contact between drug users and service providers. Syringe exchange strategies multiply their benefits if they also include AIDS education, counselling and referral for medical treatment.

HIV prevention programmes focusing on injecting users should not neglect sexual risk behaviour among people who inject drugs or use other substances. The epidemiological evidence shows that HIV transmission via the sexual pathway is increasing among injecting drug users as well as among crack-cocaine* users.

Sexual risks arise in the context of other risks and dangers, such as the risks associated with overdose or needle sharing. These other risks may be more immediately perceived, and as a result, the sexual transmission of HIV among drug users tends to be overlooked.

Efforts to respond to the HIV epidemic have always shown that prevention and care are mutually reinforcing strategies. The care and support provided to drug users living with HIV/AIDS and to their families needs to include access to affordable clinical and day care, essential legal and social services, psycho-social support and counselling, as well as effective HIV prevention interventions.

Responding to the HIV/AIDS epidemic is a complex task. There are no magic recipes and no single short-cut solutions. But there are solutions. One of the keys consists of finding pragmatic, effective responses to the epidemic by working along with the injecting drug users, making sure that they actually participate in finding the solutions.

Source: PEDDRO december 2001