Symposium Urges Human Rights Approach to Treating HIV in Drug Users



AIDS and HIV infection are human rights issues and should be addressed as such, the speakers said.

"AIDS is not only an infectious disease, it's a political, social, and economic emergency," said The Lancet editor Richard Horton, MD. In this patient population, "the traditional biomedical approach to AIDS will not work." To stem the epidemic, countries and clinicians around the world must grant HIV-infected drug users access to adequate healthcare services without turning them into criminals, forced laborers, or pariahs.

There are about 16 million injecting drug users (IDUs) in at least 148 countries, and their ranks are growing. It is estimated that from 3 million to as many as 6.6 million of those people are HIV-positive. Outside of sub-Saharan Africa, IDUs account for about one third of HIV disease around the world. Unfortunately, Dr. Horton said, complacency, homophobia, bigotry, and just plain ignorance on the part of officials and clinicians in those nations only compound the problems caused by drug abuse and HIV infection.

Good evidence suggests that IDUs who are HIV-positive benefit from a triple-pronged approach to treatment, consisting of opioid substitution therapy (OST), needle and syringe programs, and antiretroviral therapy, said Steffanie A. Strathdee, PhD, associate dean of global health sciences at the University of California–San Diego. She and her colleagues created computer models to estimate the extent to which this approach could reduce HIV prevalence in parts of the world where the epidemic was associated with drug dependence. "One of our most important findings was the synergistic nature of these interventions," she told listeners. They determined that reducing the unmet need for each part of the triad by 60% would lower HIV infection by 41% in Odessa, Ukraine; by 43% in Karachi, Pakistan; and by 30% in Nairobi, Kenya.

Despite clear evidence that OST works, it is not available in many of the countries in which the epidemic is worst, said Louisa Degenhardt, PhD, from the National Drug and Alcohol Research Center, University of New South Wales, Sydney, Australia. Even more-tolerant areas such as Western Europe and North America do not have meaningful needle-exchange programs, and OST, although present in 75 countries, is absent in 76 countries hardest-hit by the epidemic. Worldwide, only 8 of every 100 IDUs have access to OST.

Five countries in particular — China, Vietnam, Russia, Ukraine, and Malaysia — claim 47% of all infected drug users in low- and middle-income nations, noted Daniel Wolfe, MPH, from the International Harm Reduction Program of the Open Society Institute in New York City.

In Russia, IDUs account for 83% of all HIV cases, and in Malaysia, they account for 70%. Yet only about 25% of the patients most in need are receiving antiretroviral therapy, and fewer than 2% have access to OST.

The barriers to care are daunting: IDUs seeking treatment in those nations may be charged high fees for unnecessary tests or drugs. In some countries, HIV clinics will not treat people with tuberculosis, and tuberculosis clinics turn away people with HIV. In Russia, drug-treatment centers do not accept people who show up under the influence. Some of these countries require IDUs who want treatment to register with the police, who then harass patients, prevent them from obtaining jobs, and may even force them to submit to urine tests when they enroll their children in school. In some places, healthcare givers provide local authorities with the names of people coming for help with a drug problem. Patients may be thrown into jail and offered no treatment for their drug dependence or their HIV infection. In some places, "treatment" consists of forced labor in sweatshops for private companies, essentially turning patients into slaves.

Russia and Ukraine regulate opioid use so harshly through restrictions on which clinicians can prescribe them, setting arbitrary dose limits, and establishing rules governing where the drugs can be dispensed and for how many days before a new prescription is needed, that even non-drug-using cancer patients often go without pain relief.

In his concluding comments, Chris Beyrer, MD, from the Center for Public Health and Human Rights at Johns Hopkins University in Baltimore, Maryland, issued a call to action. "We know enough to act now," he said. In particular, it has been demonstrated that needle exchange, OST, and antiretroviral therapy work synergistically to reduce the incidence of HIV infection: "You need all 3."

He also challenged healthcare professionals in these regions to start advocating for their patients, rather than colluding with local authorities. "The use of detention for people who abuse drugs, with forced detoxification and forced labor, must stop." The war on drugs may have failed, Dr. Beyrer said, "but the war on HIV cannot fail."

None of the speakers has disclosed any relevant financial relationships.


(2010-07-24/Medscape)