The Connection between HIV infection in injecting drug users and drugs policy
Director of Alcohol & Drug Services St. Vincents Hospital New South Wales Australia
The control of HIV infection in the third wave of the AIDS epidemic - i.e. a in the non-drug using heterosexual community - will depend, in most western countries, on the success or failure of efforts to control the second wave of the epidemic - i.e. the spread of HIV infection in injecting drug users (IDU's). Just as IDU's are central in efforts to delay and minimise the spread of HIV infection in the general community, so too is drugs policy central to efforts to stem the spread of HIV infection in IDU's.
Policy on the spread of HIV infection must be based on our worst fears rather than our best hopes. We are entitled to hope that a vaccine against HIV will become available, but we must acknowledge the difficulties of achieving the development of an effective vaccine against a rapidly mutating retro-virus which shares many features with other viruses against which no vaccine has been prepared thus far. In any event, experience with development of simpler vaccines and their utilisation instructs us to be cautious, especially about the difficulties of arranging vaccination on a mass scale. We must also be mindful of the obstacles to widespread vaccination, which includes cost and logistical problems. Similarly, although we can be grateful for the rapid advances in treatment of HIV infection, treatment at present is still very expensive, does not return a significant proportion of keated patients to reasonable health or employment, and possibly may not reduce the risk of HIV transmission from seropositive patients who now survive for longer periods.
In many countries, IDU's are likely to be the major conduit for dissemination of HIV infection to the general community, and will be the parents of the paediatric AIDS cases. Moreover, IDU's require a disproportionately larger portion of AIDS resources compared to others involved in HIV-risk activities.
Consequently, these considerations suggest that more emphasis should be placed on efforts to prevent the further spread of HIV infection in the critical population of IDU's. Although substantial proportions of IDU's are already infected with HIV in a number of cities in Western Europe and North America, there are still many other cities with very little infection in this population, and large numbers of uninfected IDU's even in high prevalence areas. It is therefore imperative that full advantage is made of the opportunity to delay the spread of HIV infection in IDU's in high prevalence as well as low prevalence areas.
Recent data on HIV infection or AIDS are alarming. HIV infection or AIDS has been recently reported in new populations of IDU's in Poland in Eastern Europe, Thailand in South East Asia, Brazil and Argentina in South America and in some Caribbean countries. HIV infection in IDU's in a number of other countries must be regarded as inevitable and imminent. It is imperative that maximum efforts are made to delay the onset and minimise the peak level of HIV infection in IDU's.
What then is the role of drug policy in containing the spread of HIV infection in IDU's?
At present, IDU's in most western countries usually inject drugs rather than using alternative routes of administration principally because street drugs are expensive and impure. Experience has shown that where drugs are less expensive and of higher purity, users will also sometimes inhale or ingest their drugs. Reducing the supply results in street drugs having low purity and high price. Indeed, these parameters are regarded as criteria of successful supply reduction. However, in order to stem the spread of HIV infection in injecting drug users, we should encourage drug policies which result in cheaper street drugs of higher purity.
Discouraging drug users from injecting drugs should have the highest priority. Substitution from injecting to other forms of administration is preferable to continued injecting, which is associated with the practice of sharing of injecting equipment and consequent risk of HIV infection. The extent of substitution of non-injecting routes of administration will be partly determined by drugs policy. Even if cheaper, purer street drugs increase the number of users, and there is no way of determining the effect of policy on pool size, the risk of H5infection may still be reduced if a major switch to non-parental routes is achieved.
One of the major factors in sharing of used needles and syringes, and the consequent spread of HIV infection, is unavailability of sterile injection equipment. At present in Australia there are between 30,000 and 100,000 IDUs, injecting anywhere between one and four times a day. This means that there may be anywhere between 40 and 60 million injections of street drugs in Australia per annum. Currently, between 2 million and 3 million sterile needles and syringes are provided annually. It is unlikely that this level of intervention is sufficient to achieve the maximum reduction in spread of HIV infection in this population. Although cost and logistical problems are important obstacles to expansion of needle and syringe programmes, it is also apparent that current drug policies delay the introduction and maximum implementation of this preventive strategy.
Evidence from a number of studies has now demonstrated that drug users in treatment generally have lower rates of HIV seroprevalence than drug users not in treatment. It is now also apparent that drug users in treatment for longer periods have
lower seroprevalence than drug users in treatment for shorter periods. The same is true for drug users on lower doses of methadone. We do not have sufficient evidence as yet to be categorical, but it is likely that increasing the proportion of
drug users who are in treatment will slow the spread of HIV infection. This requires increasing the capacity of treatment and adapting treatment so that it becomes far more attractive to IDU's. Both of these objectives can only be achieved by substantial
liberalisation of existing drugs policy so that the priority of containing the spread of HIV infection in IDU's becomes paramount above other concerns. Liberalising drugs policy will also reduce the per-capita cost of drugs treatment.
Behaviours associated with the risk of transmission of HIV infection are believed to be prevalent in prisons, although it is difficult to measure the frequency of their occurrence. Evidence to support the widespread fear that substantial HIV infection occurs in prisons is lacking but this may be due to insufficient studies, poor methodology, or inappropriate generalisability from existing studies. Therefore, it must be assumed that a substantial risk of HIV infection does occur in prisons. If the number of drug users at risk of HIV infection in prisons is to be reduced, every effort must be made to divert prisoners convicted only of drug related offences from prisons to non custodial forms of sentencing. This can only be achieved by liberalisation of drugs policy.
At present, efforts to educate and otherwise modify the behaviour of IDU's is impeded because the target population is ostracised and marginalised. These problems can only be overcome (and partly at that), by liberalisation of drugs policy. It is generally accepted that the introduction of peer based education was an important step in the development of effective programmes for homosexual/bisexual males. This component of education for IDU's has been delayed by current drug policies. Indeed, the lack of organisations of IDU's in western countries, until recent times, has been one of the factors responsible for the less than enthusiastic efforts to introduce HIV prevention strategies for IDU's. It is hard to envisage the existence of organisations for self-declared IDU's in the presence of strongly enforced supply reduction policies.
Our efforts must now be expended on developing credible alternative options to existing drug policy and reviewing the international and historical experience with controlled availability of currently illicit drugs. The obstacles to drug policy reform also need to be more clearly identified. If liberalisation of drug policy is the price which must be paid for containing the spread of HIV infection in IDU's, it is a price well worth paying.