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Global, regional, and country-level coverage of interventions to prevent and manage HIV and hepatitis C among people who inject drugs: a systematic review
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Reviews of the global prevalence of injecting drug use and of interventions to prevent the spread of blood-borne viruses among people who inject drugs paint a worrying picture.
24 Oct 2017
Lancet Global Health - Oct 23 2017 - Sarah Larney, Amy Peacock, Janni Leung, Samantha Colledge, Matthew Hickman, Peter Vickerman, Jason Grebely, Kostyantyn V Dumchev,
Paul Griffiths, Lindsey Hines, Evan B Cunningham, Richard P Mattick, Michael Lynskey, John Marsden, John Strang, Louisa Degenhardt
⋅ 15⋅6 million (uncertainty interval [UI] 10⋅2-23⋅7 million) people inject drugs
⋅ Less than 1% of all PWID live in countries with high coverage of both NSP and OST.
⋅ HCV antibody prevalence from 50% (38-63) in east and southeast Asia to 65% (57-73) in eastern Europe Rapid scale-up of NSP and OST is urgently needed in regions where injecting drug use is an emerging issue, such as sub-Saharan Africa.....
⋅ Russia (with an estimated 1⋅9 million PWID [UI 1⋅0-3⋅1], 30% [18-43] of whom are estimated to be living with HIV, and 69% [60-78] with HCV antibodies)1 is the only country in the eastern European region that does not provide OST, and access to NSP is very limited.
⋅ The three regions with the largest populations of PWID-east and southeast Asia, eastern Europe, and North America-were all estimated to have poor coverage of NSP and OST. These are all regions where injecting drug use is well established. HIV prevalence in these regions is estimated to range from 9% (UI 7-11) in North America to 25% (16-34) in eastern Europe, and .......
⋅ HCV antibody prevalence from 50% (38-63) in east and southeast Asia to 65% (57-73) in eastern Europe
⋅ The three regions worldwide with the highest populations of people who inject drugs, East and South-East Asia, Eastern Europe and North America, all had poor provision of needle syringe programs and opioid substitution therapy.....
⋅ WHO, UNAIDS, and the UN Office on Drugs and Crime (UNODC) supports a comprehensive package of interventions for the prevention and treatment of HIV and HCV infections among PWID.
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Reviews of the global prevalence of injecting drug use and of interventions to prevent the spread of blood-borne viruses among people who inject drugs paint a worrying picture.
24 Oct 2017
https://newsroom.unsw.edu.au/news/health/new-perspectives-risk-hiv-and-hepatitis-among-injecting-drug-users
The provision of programs to prevent the spread of HIV and hepatitis among people who inject drugs (PWID) is inadequate in many countries around the world and presents a critical public health problem, comprehensive reviews by Australian researchers from the National Drug and Alcohol Research Centre at UNSW Sydney have found.
The two reviews of the global prevalence of injecting drug use and of interventions to prevent the spread of blood borne viruses among PWID are published today in leading international journal The Lancet Global Health. Pdf aattached
The authors estimate that 15.6 million people have recently injected drugs. Of these, 18% are living with HIV infection and 52% test positive for hepatitis C (HCV) antibody.
Yet despite evidence that needle and syringe programs (NSP) and opioid substitution therapy (OST) reduce HIV and HCV infections, they are still not being implemented in many places, and few people can access them in many countries, the authors found.
Australia is one of only four countries worldwide with high coverage of both NSP and OST - the others are Austria, the Netherlands and Norway.
In Australasia, 1.1% of PWID are living with HIV compared with 25% of PWID in Eastern Europe, 36% in Latin America, 18% in Sub Saharan Africa and 19% in South Asia.
By contrast, the prevalence of hepatitis C among PWID is more evenly spread - 57% of the people who inject drugs in Australia and New Zealand test positive for hepatitis C antibodies, compared with 64% in Central Europe, 55% in North America and 50% in East and South-East Asia.
"Across all countries, a substantial number of people who inject drugs are living with HIV or HCV and are exposed to multiple adverse risk environments that increase health harms," says UNSW's Professor Louisa Degenhardt, lead author of the paper reviewing prevalence of injecting drug use and HIV and hepatitis in this population.
The reviews of global prevalence of injecting drug use and of provision of programs to prevent the spread of blood borne viruses are the first to be conducted since 2008, although the results are not directly comparable due to different and more sophisticated data collection techniques, and better country-specific record keeping.
Evidence of injecting drug use was found in an additional 33 countries compared with the last review - predominantly from Sub Saharan Africa.
Just over half (52%) of the countries with evidence of injecting drug use had needle and syringe programs. Medical treatment to encourage reductions in injecting - opioid substitution therapy - was available in less than half of all countries identified (48%).
Opioid substitution therapy (OST) per 100 people who inject drugs. Graphic: Evan Cunningham/NDARC
UNSW's Dr Sarah Larney, lead author of the paper on global coverage of interventions, says: "Coverage of HIV and HCV prevention interventions for PWID remains poor and is likely to be insufficient to effectively prevent HIV and HCV transmission. Scaling up of interventions for PWID remains a crucial priority for halting the HIV and HCV epidemics.
"The presence of interventions alone is not sufficient; the greatest prevention benefits are reported when NSP and OST are implemented in high coverage and in combination," Dr Larney adds.
The three regions worldwide with the highest populations of people who inject drugs, East and South-East Asia, Eastern Europe and North America, all had poor provision of needle syringe programs and opioid substitution therapy.
HIV prevalence in these countries was high, ranging from 9% in North America to 25% in Eastern Europe. By contrast, only 1% of people who inject drugs in Australia and New Zealand are living with HIV.
"Several countries in these regions have experienced recent HIV outbreaks as well as persistently high HCV prevalence among PWID," write the authors.
For example, Russia, which has almost 2 million people who inject drugs - nearly 30% of whom have HIV and 69% of whom have hepatitis C - does not provide OST and has very limited access to NSP, the authors found.
Interactive dashboards containing data from this study are available on the NDARC website.
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Discussion
Implementation of core interventions to prevent and treat HIV and HCV infections among PWID is occurring in a greater number of countries than in previous years,10 but information on intervention coverage is often not available, and where available, suggests that coverage remains poor in many countries. NSP and OST are identified by WHO and UNAIDS as the highest priority of the core interventions,9 but on the basis of available data, only ten and 19 countries, respectively, are meeting suggested NSP and OST high-coverage targets. Less than 1% of all PWID live in countries with high coverage of both NSP and OST. Compared with the other interventions reviewed, there were considerably fewer data available on HIV testing and ART access among PWID. However, where data were available, coverage was typically low in comparison with suggested targets.5
The three regions with the largest populations of PWID-east and southeast Asia, eastern Europe, and North America-were all estimated to have poor coverage of NSP and OST. These are all regions where injecting drug use is well established. HIV prevalence in these regions is estimated to range from 9% (UI 7-11) in North America to 25% (16-34) in eastern Europe, and HCV antibody prevalence from 50% (38-63) in east and southeast Asia to 65% (57-73) in eastern Europe.1 Several countries in these regions have experienced recent HIV outbreaks as well as persistently high HCV prevalence among PWID,4, 28, 29 highlighting the need for better access to prevention interventions. Of particular concern, Russia (with an estimated 1⋅9 million PWID [UI 1⋅0-3⋅1], 30% [18-43] of whom are estimated to be living with HIV, and 69% [60-78] with HCV antibodies)1 is the only country in the eastern European region that does not provide OST, and access to NSP is very limited.
Rapid scale-up of NSP and OST is urgently needed in regions where injecting drug use is an emerging issue, such as sub-Saharan Africa. Of the 37 countries in that region where injecting drug use has now been reported, only seven offer NSP, and eight OST. Coverage of these interventions is very low at the regional level: just two needle-syringes distributed per PWID per year (UI <1-4), and one person receiving OST per 100 PWID (UI <1-2). HIV prevalence among PWID in the region is estimated at 18% (UI 11-25), similar to the global estimate of 18% (11-25);1 however, HCV antibody prevalence is 22% (18-27), much lower than the global estimate of 52% (42-62).1 Increased intervention coverage will contribute to reduced HIV transmission and prevent further escalation of the HCV epidemic among PWID in sub-Saharan Africa.
There is often considerable uncertainty around estimates of injecting drug use prevalence, which translates into uncertainty in estimates of intervention coverage. Methods and definitions used to calculate estimates of injecting drug use differ across countries and over time. We have avoided directly comparing these estimates to previously derived estimates, as differences in methodology and data sources might explain some apparent changes over time. The estimates reported here might differ from those of some national or regional reporting bodies due to differences in methodology and data sources included. To facilitate transparency in reporting, we have provided references for all datapoints used to generate these estimates in the appendices, as well as online interactive presentations of these data. We encourage feedback regarding the estimates via email.
Much of the indicator data reported here were derived from reports produced by government, intergovernmental, and non-government organisations. The quality of such data depends largely on existing monitoring systems and capacity within a country to collect data in a timely and representative manner. Establishing and maintaining monitoring systems requires dedicated resources. Without these, reporting against defined indicators can be poor. Some reports provided an estimate of intervention coverage without the data used to inform the estimate (eg, an estimate of the number of needle-syringes distributed per PWID per year, but without the population size and numerator used for this calculation). We did not use such estimates in this review, as we were unable to assess their validity. Lack of transparency in reporting can easily be remedied by providing the data used to generate estimates (ie, denominator and numerator), as well as the estimates themselves.
Compared with NSP and OST, data for HIV testing, ART, and condom distribution programmes specifically for PWID appear less likely to be systematically and routinely collected and reported. This is in part due to the interventions being applicable to the broader population, but also because HIV testing and treatment programmes might not collect or report data on risk exposure due to concerns regarding stigma or criminal justice implications for PWID. Given the potential for negative consequences for the patient, WHO guidelines on ART programme monitoring recommend against recording data related to patient risk behaviours in ART registers (as distinct from case surveillance data).30 Without such data, though, it is difficult to assess the extent to which particularly vulnerable populations are accessing these interventions.
Survey data might go some way towards addressing this problem, but to do so, surveys must employ recruitment methods that minimise risk of selection bias in findings. Recruitment of PWID from multiple community settings (not solely treatment or other services), such as through respondent-driven sampling or structured chain referral methods, can minimise selection bias.31, 32, 33 In presenting survey data, basic parameters including the precise indicator that was measured, sample size responding to the survey item, and numerator, should be presented in addition to the calculated proportion and associated uncertainty.
Clinic exit surveys are an alternative approach to estimating coverage of ART and other service use among PWID (and other key populations) being considered. Clients attending clinics providing ART (or other interventions) could complete a short survey via a tablet with results being immediately transmitted to a secure server separate from the clinic. This could involve a small number of questions including services received, viral load, mode of transmission, and current behaviours (including injecting drug use). If undertaken at large clinics across countries, this approach would permit estimates of the percentage of ART clients who inject drugs, which could be used to generate the number of PWID clients at the country level.
Although we did a comprehensive, multilingual search for relevant data, some data might have been overlooked. Grey literature, such as reports from organisations providing services or by government departments, can be difficult to locate, even when published online. To address this, we worked directly with staff from WHO, UNAIDS, the Global Fund, UNODC, and EMCDDA, and contacted experts around the world for assistance in identifying and verifying data. Uncertainty can occur in interpreting indicator data, as they are sometimes reported without contextual details (eg, the time frame to which data referred), or such details are unclear. All extracted data were checked multiple times by senior team members, and we sought clarification from people familiar with the data or context (eg, local researchers, service providers, and staff of intergovernmental organisations) if needed. Data searching and verification through contact with in-country experts continued until August, 2017, to ensure we included the most recent programme data possible.
We have provided regional estimates of NSP, OST, and, for some regions, HIV testing coverage. For countries where an intervention was known to be in place, but no programme data were available, we assumed that coverage in that country was the same as in other countries in the same region. For some countries, this might have resulted in overestimation or underestimation of true coverage, affecting the validity of the regional estimates. We suggest caution in interpreting the regional estimates as precise indications of intervention coverage; rather, we provide them to highlight regional differences and areas for particular focus for investment of resources.
In some cases, estimates for OST, HIV testing, and ART coverage per 100 PWID were greater than parity. This is likely a result of programme data categorising individuals as PWID on the basis of lifetime injecting drug use, whereas our PWID population size data refer to recent injecting drug use. As such, our approach might overestimate service access among recent PWID.
Prescribing of direct-acting antiviral therapies has recently become an important component of HCV prevention and treatment efforts.34 We did not explicitly search for indicators relating to treatment of HCV infection among PWID, such as HCV testing, treatment uptake, or outcomes of treatment, as we judged that at this time, there would be very limited data available for estimating these indicators at the population level. Future iterations of this work should include indicators such as the number of PWID who have received HCV antibody and diagnostic testing, and the number with chronic HCV infection who have been treated and cured.
Prisons and other correctional institutions are important settings for HIV and HCV prevention among people who inject drugs. We did not report on intervention coverage in these settings. Previous work has found that few countries permit NSP in prisons.14 OST is provided in prisons in 52 countries, although programmes often exist on a small scale or in a limited number of institutions.14 Determining coverage of HIV and HCV prevention interventions in prisons is complicated by a lack of data on the number of PWID in prisons. Further work to determine PWID population sizes and coverage of prevention interventions in prisons is needed to understand where gaps in HIV and HCV prevention might exist.
Greater investment in HIV and HCV prevention and treatment is urgently needed for the 16 million PWID globally.1 Effective interventions for HIV and HCV among PWID are delivered at suboptimal levels in almost all countries. Failure to provide interventions to scale ensures ongoing high prevalence and incidence of HIV and HCV infections among PWID, who are being left behind in efforts to end the HIV and HCV epidemics. Concerted international efforts will be required to ensure high coverage of interventions, particularly NSP and OST, is achieved and maintained.
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