Estimates are not enough: scaling-up interventions to improve the health of people who inject drugs

At the UN General Assembly Special Session on the world drug problem (UNGASS) in New York, in April, 2016, member states reaffirmed their commitment to effectively addressing and countering the world drug problem. They also reiterated their commitment to ending the HIV and tuberculosis epidemics by 2030 and to combating viral hepatitis and other communicable diseases, among other things, in people who inject drugs (PWID).1United Nations Office on Drugs and CrimeOutcome document of the 2016 United Nations General Assembly Special Session on the world drug problem. United Nations, New York2016Google Scholar This issue of The Lancet Global Health features two comprehensive reviews deriving estimates of country, regional, and global prevalence of injection drug use (IDU), blood-borne infections, and coverage of harm reduction services.2Degenhardt L Peacock A Colledgeet S et al.Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic review.Lancet Glob Health. 2017; (published online Oct 23.)http://dx.doi.org/10.1016/S2214-109X(17)30375-3Summary Full Text Full Text PDF Scopus (788) Google Scholar, 3Larney S Peacock A Leung J et al.Global, regional, and country-level coverage of interventions to prevent and manage HIV and hepatitis C among people who inject drugs: a systematic review.Lancet Glob Health. 2017; (published online Oct 23.)http://dx.doi.org/10.1016/S2214-109X(17)30373-XSummary Full Text Full Text PDF Scopus (261) Google Scholar These Articles are timely, as they provide much needed data for the future evaluation of progress towards achieving these targets. Louisa Degenhardt and colleagues2Degenhardt L Peacock A Colledgeet S et al.Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic review.Lancet Glob Health. 2017; (published online Oct 23.)http://dx.doi.org/10.1016/S2214-109X(17)30375-3Summary Full Text Full Text PDF Scopus (788) Google Scholar and Sarah Larney and colleagues3Larney S Peacock A Leung J et al.Global, regional, and country-level coverage of interventions to prevent and manage HIV and hepatitis C among people who inject drugs: a systematic review.Lancet Glob Health. 2017; (published online Oct 23.)http://dx.doi.org/10.1016/S2214-109X(17)30373-XSummary Full Text Full Text PDF Scopus (261) Google Scholar made extensive efforts to obtain data from various sources, including grey literature and additional data from international experts and agencies, and applied innovative methods to improve the robustness of their estimates. They provide the most comprehensive estimates generated so far of the coverage of harm reduction services for PWID and the prevalence of IDU and HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) infection among PWID. Although IDU might not be uniformly defined across countries, the study by Degenhardt and colleagues shows that an estimated 15·6 million (95% uncertainty interval [UI] 10·2–23·7 million) people aged 15–64 years around the world inject drugs, corresponding to a global prevalence of 0·33% (95% UI 0·21–0·49), of whom 80% are men.2Degenhardt L Peacock A Colledgeet S et al.Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic review.Lancet Glob Health. 2017; (published online Oct 23.)http://dx.doi.org/10.1016/S2214-109X(17)30375-3Summary Full Text Full Text PDF Scopus (788) Google Scholar The largest populations of PWID live in east and southeast Asia, eastern Europe, and North America. Ageing populations of PWID in Europe, North America and Australasia suggest decreasing trends in the prevalence of IDU,1United Nations Office on Drugs and CrimeOutcome document of the 2016 United Nations General Assembly Special Session on the world drug problem. United Nations, New York2016Google Scholar, 4European Monitoring Centre for Drugs and Drug AddictionEuropean Drug Report 2017: Trends and Developments. Publications Office of the European Union, Luxembourg, Luxembourg2017Google Scholar although recent outbreaks of IDU and associated infections have been seen in some countries within these regions (eg, Greece and the USA).5Banerjee G Edelman EJ Barry DT et al.Non-medical use of prescription opioids is associated with heroin initiation among US veterans: a prospective cohort study.Addiction. 2016; 111: 2021-2031Crossref PubMed Scopus (77) Google Scholar, 6Paraskevis D Kostaki E Nikolopoulos GK et al.Molecular tracing of the geographical origin of HIV-1 infection and patterns of epidemic spread among migrants who inject drugs in Athens.Clin Infect Dis. 2017; (published online Aug 16.)DOI:10.1093/cid/cix717Crossref PubMed Scopus (16) Google Scholar Degenhardt and colleagues saw an improvement in the documentation of IDU in recent years, in particular with new data coming from sub-Saharan Africa.2Degenhardt L Peacock A Colledgeet S et al.Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic review.Lancet Glob Health. 2017; (published online Oct 23.)http://dx.doi.org/10.1016/S2214-109X(17)30375-3Summary Full Text Full Text PDF Scopus (788) Google Scholar However, estimates of IDU prevalence were only available for 40% of 206 countries and territories globally. Hence, the data continue to be incomplete. Globally 17·8% of PWID are estimated to live with HIV infection, 9·0% with HBV, and 52·3% with HCV infection. Among PWID, eastern Europe and Latin America have the highest HIV and HCV prevalence and east and southeast Asia the highest HBV prevalence.1United Nations Office on Drugs and CrimeOutcome document of the 2016 United Nations General Assembly Special Session on the world drug problem. United Nations, New York2016Google Scholar Growing evidence suggests that participation in comprehensive harm reduction programmes incorporating needle and syringe programmes (NSP) and opioid substitution therapy (OST) is associated with a reduced risk of acquiring HIV and HCV infection.7Fernandes RM Cary M Duarte G Effectiveness of needle and syringe programmes in people who inject drugs—an overview of systematic reviews.BMC Public Health. 2017; 17: 309Crossref PubMed Scopus (118) Google Scholar, 8Platt L Minozzi S Reed J et al.Needle and syringe programmes and opioid substitution therapy for preventing HCV transmission among people who inject drugs: findings from a Cochrane Review and meta-analysis.Addiction. 2017; DOI:10.1111/add.14012Crossref PubMed Scopus (185) Google Scholar When combined with health promotion programmes (including sexual health), testing, vaccination (for HBV), and treatment of infections, elimination of infections might even be feasible over the long term, as suggested by results from mathematical models.9Martin NK Vickerman P Hickman M How to eliminate HCV infection by antiviral treatment.J Hepatol. 2017; 67: 5-6Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar However, the coverage of NSP, OST, and HIV services for PWID, estimated with similarly extensive methods in the Article by Larney and colleagues, is very limited.3Larney S Peacock A Leung J et al.Global, regional, and country-level coverage of interventions to prevent and manage HIV and hepatitis C among people who inject drugs: a systematic review.Lancet Glob Health. 2017; (published online Oct 23.)http://dx.doi.org/10.1016/S2214-109X(17)30373-XSummary Full Text Full Text PDF Scopus (261) Google Scholar Of the countries and territories with evidence of IDU, only 52% reported the presence of NSP and 48% reported the presence of OST. The situation is even worse for the uptake of comprehensive harm reduction programmes: the authors estimate that, globally, less than 1% of PWID live in countries with a high coverage of both NSP and OST. It is important to note that many countries in the most affected regions criminalise drug use (with some still having death penalties for drug offences), do not allow access to harm reduction services, or both. Larney and colleagues also showed that data on HIV testing and antiretroviral therapy (ART) access for PWID were available for only a minority of countries,3Larney S Peacock A Leung J et al.Global, regional, and country-level coverage of interventions to prevent and manage HIV and hepatitis C among people who inject drugs: a systematic review.Lancet Glob Health. 2017; (published online Oct 23.)http://dx.doi.org/10.1016/S2214-109X(17)30373-XSummary Full Text Full Text PDF Scopus (261) Google Scholar in line with evidence showing that PWID are lagging behind in HIV and HCV treatment uptake compared with other key populations.10van Santen DK van der Helm JJ Lindenburg K Schim van der Loeff M Prins M HIV and hepatitis C treatment uptake among people who use drugs participating in the Amsterdam Cohort Studies, 1985–2015.Int J Drug Policy. 2017; 47: 95-101Crossref PubMed Scopus (15) Google Scholar Although the two systematic reviews show that some progress has been made in the estimation of IDU and infection prevalence, they also brutally underscore the absence of significant improvement in the scaling-up of increasingly well documented, evidence-based interventions to prevent new infections among PWID in countries and regions with expanding epidemics. Since harm reduction programmes also have a key role in linking PWID to HBV vaccination, HIV pre-exposure and post-exposure prophylaxes, and testing and treatment for HIV, HCV, and HBV, scaling-up of comprehensive prevention programmes for PWID remains a major challenge. International collaborations, political commitment, and investment are needed in the next few years to limit structural barriers and increase access to harm reduction and other health-care services, in particular in regions with emerging and ongoing epidemics of IDU and infection. The failure of the 2016 UNGASS to produce substantial changes to international drug policy11Bewley-Taylor D Jelsma M Drug policy briefing 45. UNGASS 2016. A broken or B-r-o-a-d concensus?. Transnational Institute, Amsterdam2016Google Scholar underlines that these efforts will not be sufficient to maximise the potential effect of services. We urgently need to discuss and take regional and global actions, including revisiting international drug control conventions, to provide PWID with appropriate services to improve their quality of life and reduce harms to society, communities, and individuals. We declare no competing interests. Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic reviewWe identified evidence of IDU in more countries than in 2008, with the new countries largely consisting of low-income and middle-income countries in Africa. Across all countries, a substantial number of PWID are living with HIV and HCV and are exposed to multiple adverse risk environments that increase health harms. Full-Text PDF Open AccessGlobal, regional, and country-level coverage of interventions to prevent and manage HIV and hepatitis C among people who inject drugs: a systematic reviewCoverage 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. Full-Text PDF Open Access

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