Elsevier

The Lancet

Volume 375, Issue 9719, 20–26 March 2010, Pages 1014-1028
The Lancet

Articles
HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage

https://doi.org/10.1016/S0140-6736(10)60232-2Get rights and content

Summary

Background

Previous reviews have examined the existence of HIV prevention, treatment, and care services for injecting drug users (IDUs) worldwide, but they did not quantify the scale of coverage. We undertook a systematic review to estimate national, regional, and global coverage of HIV services in IDUs.

Methods

We did a systematic search of peer-reviewed (Medline, BioMed Central), internet, and grey-literature databases for data published in 2004 or later. A multistage process of data requests and verification was undertaken, involving UN agencies and national experts. National data were obtained for the extent of provision of the following core interventions for IDUs: needle and syringe programmes (NSPs), opioid substitution therapy (OST) and other drug treatment, HIV testing and counselling, antiretroviral therapy (ART), and condom programmes. We calculated national, regional, and global coverage of NSPs, OST, and ART on the basis of available estimates of IDU population sizes.

Findings

By 2009, NSPs had been implemented in 82 countries and OST in 70 countries; both interventions were available in 66 countries. Regional and national coverage varied substantially. Australasia (202 needle–syringes per IDU per year) had by far the greatest rate of needle–syringe distribution; Latin America and the Caribbean (0·3 needle–syringes per IDU per year), Middle East and north Africa (0·5 needle–syringes per IDU per year), and sub-Saharan Africa (0·1 needle–syringes per IDU per year) had the lowest rates. OST coverage varied from less than or equal to one recipient per 100 IDUs in central Asia, Latin America, and sub-Saharan Africa, to very high levels in western Europe (61 recipients per 100 IDUs). The number of IDUs receiving ART varied from less than one per 100 HIV-positive IDUs (Chile, Kenya, Pakistan, Russia, and Uzbekistan) to more than 100 per 100 HIV-positive IDUs in six European countries. Worldwide, an estimated two needle–syringes (range 1–4) were distributed per IDU per month, there were eight recipients (6–12) of OST per 100 IDUs, and four IDUs (range 2–18) received ART per 100 HIV-positive IDUs.

Interpretation

Worldwide coverage of HIV prevention, treatment, and care services in IDU populations is very low. There is an urgent need to improve coverage of these services in this at-risk population.

Funding

UN Office on Drugs and Crime; Australian National Drug and Alcohol Research Centre, University of New South Wales; and Australian National Health and Medical Research Council.

Introduction

In 2007, between 11·0 million and 21·2 million people worldwide were estimated to be injecting drug users (IDUs).1 Injecting drug use is an important cause of HIV transmission around the world; between 0·8 million and 6·6 million IDUs were estimated to be infected with HIV in 2007,1 accounting for a substantial proportion of the 33 million people (range 30–36 million) living with HIV worldwide.2

HIV is an important contributor to the burden of disease attributable to drug use worldwide3 and has the potential to spread to the wider community by sexual transmission.4 Effective public health interventions are needed to address HIV in IDUs. A range of core interventions are effective in preventing HIV in this population, including provision of clean needles and syringes (typically through needle and syringe programmes; NSPs) to avoid HIV transmission by sharing of contaminated injecting equipment;5, 6 treatment of opioid dependence with opioid substitution therapy (OST), particularly methadone and buprenorphine, leading to reductions in drug injection and HIV risk behaviours;7 and other forms of drug treatment might also reduce injecting risk.5 Treatment of HIV-positive IDUs with antiretroviral treatment (ART) leads to improved health outcomes, and might reduce HIV infectivity. Sexual transmission of HIV is also a risk for IDUs; drug treatment and condom provision have proved to reduce sexual risk behaviour.5 Interventions have maximum effect when they are delivered in combination.8

These services form part of a comprehensive package of nine interventions endorsed by the Joint UN Programme on HIV/AIDS (UNAIDS), UN Office on Drugs and Crime (UNODC), and WHO for the prevention, treatment, and care of HIV in IDUs, which also includes HIV testing and counselling; targeted information, education, and communication for IDUs and their sexual partners; vaccination, diagnosis, and treatment of viral hepatitis; and prevention, diagnosis, and treatment of tuberculosis.9

Earlier global reviews of HIV prevention and care services for IDUs have reported the existence of these services in countries where injecting drug use occurs,10 but they did not quantify the scale of coverage. A recent report reviewed coverage of OST and NSPs in European and other countries,11 but no systematic review of worldwide coverage had been undertaken. In view of the scale of the public health issues that injecting drug use and HIV represent, and to understand the global response, we need to know the types of services provided and whether these are in keeping with current HIV prevention guidelines, the extent of service provision relative to the size of IDU populations, and the degree to which these services meet the needs of the people they serve. We therefore undertook a systematic review of data for provision and coverage of HIV prevention, treatment, and care services in IDUs. Coverage estimates were calculated on the basis of available estimates of IDU population sizes.

Section snippets

Search strategy and selection criteria

This systematic review comprised five major stages (figure 1; webappendix pp 2–5). Each stage involved comprehensive searches of particular sources of information, or consultation with national, regional, and global stakeholders for critical review of the information gathered in previous stages and often provision of additional data.

In November, 2008, we searched the peer-reviewed literature databases Medline and BioMed Central for data describing the provision of HIV prevention and care

Results

Figure 1 shows the flow diagram of data selection for the analysis. Availability of data varied greatly across the 200 countries and territories examined in this systematic review, with data for existence of services more commonly available than data for extent of services (Table 1, Table 2, Table 3, Table 4, Table 5). Nonetheless, for all the indicators presented in this report, data for the extent of services were available for countries that accounted for at least 60% of the EGIP, and at

Discussion

This systematic review shows that although the number of countries with core HIV prevention services is growing, the level of coverage in IDUs is poor in many countries. For example, in 2009, 82 countries had implemented NSPs and 70 countries had implemented OST, an increase of five and eight countries, respectively, since the last global audit published in early 2008.10 Worldwide, however, the midpoint estimate of coverage of NSP, OST, and ART services in IDUs was low. Our findings suggest

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