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HIV Prevention Knowledge Base

A Collection of Research and Tools to Help You Find What Works in Prevention

Combination Approaches: Harm Reduction for Injecting Drug Users

I. Definition of Prevention Area

Drug use is a major factor in the spread of HIV infection in many settings. Sharing equipment used for injecting drugs transmits HIV, and drug use is linked with unsafe sexual activity that can increase HIV risk. Harm reduction programs focus on reducing the transmission of HIV associated with injecting drug use, while not necessarily trying to eliminate drug use itself. HIV prevention programs for injecting drug users (IDUs) may focus on decreasing needle use or needle sharing directly or by stabilizing the lives of IDUs.

II. Epidemiological Justification for the Prevention Area

The Reference Group to the United Nations on HIV and Injecting Drug Use estimates that 3 million people who inject drugs are HIV-positive (2008). While injecting drug use is of particular concern in South and Central Asia, Eastern Europe, and Russia, the practice is also growing in sub-Saharan Africa—particularly Kenya and Nigeria, which already face generalized HIV epidemics.

Sharing non-sterilized injecting equipment is one of the most efficient ways of transmitting HIV and promoting rapid spread of HIV within IDU populations. As reported by the International Harm Reduction Association in its 2008 report, in many countries, including China, India, Kenya, Myanmar, Nepal, Thailand, and Vietnam, HIV prevalence among IDUs is 50 percent or higher. Injecting drug use is associated with risky sexual behavior that may permit HIV transmission to cross into the non-IDU population. Evidence from numerous settings suggests that women injectors often exchange sex for material needs. Injection drug use is also associated with the transmission of other infectious diseases, such as hepatitis C.

Studies conducted over the past two decades confirm that harm reduction programs for IDUs consistently reduce HIV risk without increasing drug use. Medically assisted treatment (MAT) using methadone, buprenorphine, buprenorphine/naloxone (suboxone)/naltrexone or other medications/therapies and is associated with declines in HIV-related risk factors, such as injecting drug use and the number of sexual partners. The use of methadone and buprenorphine has been documented to prevent HIV transmission among IDUs. Needle and syringe programs (NSPs) are also associated with a decrease in self-reported risk behaviors among IDUs and with reduced rates of HIV transmission.

III. Core Programmatic Components

In July 2010, the President's Emergency Plan for AIDS Relief (PEPFAR) issued revised guidance on HIV prevention programming for IDUs. The guidance recognizes harm reduction as part of a comprehensive approach combining structural, biomedical, and behavioral interventions. PEPFAR recommends that programs select a combination of interventions and strategies from among the following, as their situation merits, carried out in a manner consistent with human rights obligations:

  • Community-based outreach
  • NSPs
  • MAT
  • HIV counseling and testing (HCT)
  • Antiretroviral therapy (ART) for IDUs living with HIV
  • Prevention and treatment of sexually transmitted infections (STIs)
  • Condom programs for IDUs and their sexual partners
  • Targeted information, education, and communication (IEC) for IDUs and their sexual partners
  • Vaccination, diagnosis, and treatment of viral hepatitis
  • Prevention, diagnosis, and treatment of tuberculosis (TB)

PEPFAR encourages government agencies and civil society to develop the necessary legislation, policies, and regulations to facilitate implementation and scale-up of these evidence-based services.

In recent years, there has been a rapid increase in the proportion of IDUs who are women, especially in Asia and Eastern Europe. In China, researchers have documented a rapid increase in the number of women IDUs who share injection equipment. Special attention to the unique needs of female IDUs is thus warranted.

IV. Current Status of Implementation Experience

In PEPFAR countries, only 10 percent of IDUs access NSP services, only 3.3 percent of IDUs are on MAT, and about 4 percent of HIV-positive IDUs are on ART.

Many countries in Asia and Eastern Europe have interventions for IDUs to reduce the demand for drugs. Such interventions have had limited success in preventing harmful consequences of drug use, including hepatitis C and HIV. Evidence and data from multiple programs and research studies show that harm reduction is the most successful approach to HIV programming for IDUs.

Successful programs for IDU in under-resourced countries have been characterized by:

  • A combination of behavioral, biomedical, social normative, and structural strategies and
    harm-reduction approaches that target different audiences.
  • An evidence-driven approach integrating program monitoring, evaluation, and operations
    research designed to help the program adapt to new challenges and reach newly identified
    most-at-risk populations.
  • The involvement of affected communities in all aspects of the response to the epidemic.
  • Effective linkages to government services, ensuring access to basic health care services and treatment.
  • Flexible, responsive advocacy for supportive policies and an improved regulatory environment.

The new PEPFAR guidance calls for governments to reject punitive policies that drive IDUs underground and instead actively support IDU programming to build an enabling environment for prevention.


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