People who inject drugs (PWID)
More than 80% of all HIV infections in eastern countries in the WHO European Region occur among injecting drug users (IDU). In the Russian Federation and Ukraine, IDU account for the majority of infected people (93% and 69%, respectively). Overall, access to antiretroviral treatment (ART) varies considerably between countries and subregions, but coverage is consistently low. Only 8% of people in need receive highly active antiretroviral treatment (HAART). IDU have limited access to treatment; they account for only 20% of people receiving ART.
Inequities in access to ART are most apparent in the Russian Federation and Ukraine. Access to treatment here needs to focus on IDU, most of whom are young and have poor access to any kind of services for drug abuse, HIV or other problems, such as hepatitis B and C. Making treatment available to IDU and their sexual partners on an appropriate scale is essential to achieving the goal of universal access in the European Region. Engaging such vulnerable and marginalized populations with health services, through the provision of treatment, can strengthen prevention efforts targeting some of the most unstable and rapidly growing epidemics globally.
Comprehensive, high-quality treatment and care
Given the proven effectiveness of drug dependence treatment (including opioid substitution therapy) in stabilizing IDU, and thereby increasing compliance with ART, countries should implement a comprehensive range of high-quality treatment and care services by:
- increasing access to testing and counselling, both voluntary and initiated by health service providers, in drug dependence treatment and harm reduction facilities with appropriate referral links;
- establishing substance-dependence treatment components in antiretroviral clinics;
- delivering ART through methadone and other drug-dependence treatment services;
- promoting and enhancing capacity for health and outreach workers in both drug-dependence treatment and ART settings;
- developing and publishing simplified combined treatment regimens and documenting and disseminating good practices, through building partnerships and linkages with harm reduction programmes and other partners at national, regional and global levels; and
- promoting massively scaled-up access to quality services for IDU, particularly harm reduction services and drug dependence treatment (including opioid substitution therapy) to provide entry points for treatment.
Intervention delivery through community-based and nongovernmental organizations
Recognizing that IDU in most countries are criminalized, marginalized and stigmatized, the most effective HIV/AIDS intervention programmes targeting them are delivered through community-based and nongovernmental organizations (CBOs and NGOs). Successful programmes use models of peer and professional outreach, drug-user network interventions and drug-user self-organization. These organizations and interventions need to be fully engaged in scaling up ART. This includes:
- defining the role of drug-user CBOs in supporting the global commitment to universal access;
- identifying models of service delivery, including testing and counselling and ART support through drug-user CBOs;
- production of testing and counselling and antiretroviral educational materials for drug-user communities;
- developing the capacity of drug-user CBOs through training and management support; and
- mobilizing adequate resources to ensure sustainability of such organizations.
Intensive advocacy to maintain government commitment
At the same time that CBO capacity is being developed, harm reduction and HIV/AIDS treatment and care for IDU need to be institutionalized in government services. Many governments are reluctant (and receive little public support) to invest in providing services for IDU. Intensive and convincing advocacy efforts are essential to obtaining government commitment to equitable access to ART for IDU. Establishing drug dependence treatment, particularly opioid substitution therapy, presents particular challenges in countries where legal barriers hinder prescribing methadone.
