On July 16, 2010, PEPFAR released revised guidance on comprehensive HIV prevention for people who inject drugs. The revised guidance provides support for a comprehensive package of prevention services that have been scientifically demonstrated to decrease HIV infection risk without increasing drug use, including the following three elements: (1) community-based outreach programs; (2) sterile needle and syringe programs (NSPs); and (3) drug dependence treatment, including medication-assisted treatment (MAT) with methadone, buprenorphine, and/or other effective medications as appropriate, based on the country context.

This collection of articles represents a call to arms for greater efforts to tackle the issue of HIV among people who use drugs. Commentaries address the myths surrounding drug use and HIV, and the special burden borne by women. Papers cover the risk environment for injection drug users (IDUs), HIV prevention in this population, and treatment of comorbidities among drug users living with HIV. Not only does the series look at biomedical issues such as antiretroviral HIV treatment, opioid substitution, and NSPs, it also covers social issues that prevent effective HIV prevention among IDUs and proposes a human rights-based approach to people who use drugs.

This presentation starts with big-picture data on injecting drug use and IDUs living with HIV. Using data sourced from a review of official reports and a survey of country experts, the presenters found that only 1 in 10 IDUs in PEPFAR countries use NSP services, and that those that have access to these services do not receive a sufficient annual supply of needles. Antiretroviral therapy and MAT are also only available to a tiny minority of IDUs in PEPFAR countries. The presentation highlights the barriers to service implementation and the cost of scaling up services, concluding with recommendations for future service provision targets.

These resources examine the unique issues that increase women’s risk of acquiring HIV through injecting drug use and impede their ability to seek support, treatment, and care. Female IDUs are more likely to be infected with HIV than their male counterparts because of both sexual and injection practices. Furthermore, commercial sex work and injecting drug use overlap in many countries, with IDUs more likely to work on the street and experience physical violence. Sexual health services for IDUs are rare. Female IDUs who are pregnant or mothers often lack proper antenatal care and treatment, and often suffer punitive actions from the medical and law enforcement establishments. Programs can address the issues unique to female IDUs by adopting policies that encourage women to seek drug treatment and harm reduction services; incorporating sexual and reproductive health and other women’s services into harm reduction programs; and establishing strong links between harm reduction, drug treatment, women’s shelters, and domestic violence and rape prevention services.

Based on interviews with IDUs and data from a community survey, this study found that most respondents used pharmacies to obtain needles and syringes, with only a tiny minority using syringe exchange programs (SEPs). The latter were associated with other benefits such as access to health care services. However, pharmacies were favored, partly because of geographical proximity and low cost, but also because exchanging equipment entails carrying or storing used syringes, which was associated with the risk of police interference or discovery by other people. The authors question the added value of needle exchanges versus pharmacies in resource-poor settings and argue that their data supports the introduction of a distribution model based on established formal and informal networks.

This review of over 650 articles on harm reduction strategies found that most strategies concerned illicit drugs. The review found compelling evidence to show that NSPs and outreach are useful and cost-effective, but findings to support noninjecting routes of administration, supervised injecting facilities, and naloxone distribution are only beginning to emerge. The existing evidence on brief interventions, HIV testing, and education is not conclusive. The review also evaluates harm reduction as a policy approach and finds that despite difficulties interpreting data, the evidence supports harm reduction as a driver of policy rather than just the basis of individual interventions.

The authors of this literature review argue that HIV infection is a behavioral disease, one that is strongly influenced by its surrounding environment. To develop effective HIV prevention programs, we must understand how the environment affects the risk of HIV among IDUs. Social and structural factors that may increase HIV risk are numerous: population movement, neighborhood disadvantage, public injecting spaces, and the criminal justice system, among others. The authors posit that the future of HIV prevention among IDUs depends on the extent structural and environmental interventions are promoted.

Some states in the United States have antidrug policies that include restricting the sale of syringes only to those with a prescription. Some researchers argue that such restrictions increase the extent to which IDUs share syringes and perhaps other drug paraphernalia. This cross-sectional analysis compared HIV prevalence and incidence among IDUs in the 96 largest metropolitan areas in the United States based on whether syringes were available OTC. The average HIV prevalence among IDUs in areas allowing OTC sales of syringes was 7 percent, but 14 percent in those with anti-OTC laws, a statistically significant difference. The difference in estimated average HIV incidence among IDUs was even greater: 61 percent in anti-OTC areas versus 17 percent in the other areas. Furthermore, there was no difference in the percentage of IDUs in each area, indicating that anti-OTC policies may have no effect on drug use. While these results may be due to other factors, this study does support that an association exists between anti-OTC policies and increased HIV levels.

This briefing explains the relationship between injecting drug use and HIV transmission in the context of prisons, citing examples from Lithuania and South Africa to illustrate the vulnerability of prison populations to HIV. It describes the key requirements for interventions in prisons and highlights the importance of introducing harm reduction measures such as NSPs. Although some countries have introduced limited harm reduction programs in prisons, lack of political will, policies that favor zero tolerance over evidence-based harm reduction, and negative public attitudes toward drug users are significant obstacles to widespread introduction of programs targeting this vulnerable population.

This report describes the expansion of harm reduction services that came about with the opening of North America's first medically-supervised safer injection facility in Vancouver, Canada. The study used various statistical models to estimate the number of deaths averted among users of the facility versus the neighborhood in which it is situated. The authors found that, even using the most conservative published estimates of the neighborhood ratio of nonfatal to fatal overdoses, the safer injecting facility averted deaths due to overdose among its users. The data support the facility's positive public health impact.

This review of studies on the use of needle and syringe dispensing machines and mobile vans by needle and syringe programs evaluates their effectiveness in reaching IDUs who are otherwise not easily reached. Typical hard-to-reach IDUs include those who are homeless, young, female, from an ethnic minority, prisoners, or new injectors. The review showed that mobile vans have gained more acceptance than dispensing machines, but also that the services complement each other. Dispensing machines offer complete anonymity at the expense of interaction with health staff, while mobile vans mitigate the lack of anonymity with greater convenience for clients and acceptability by local residents.

Site visits and interviews with multiple stakeholders working in harm reduction in the Kyrgyz Republic formed the basis for this report documenting current best practices. While most former Soviet countries continued with the punitive Soviet model of treating IDUs, the Kyrgyz Republic adopted harm reduction on multiple levels. Best practices detailed include mobilizing stakeholders across various government offices, donor coordination, syringe and needle exchange programs, and harm reduction in prisons. While efforts were too new and on too small a scale to show changes in key macro-level indicators, project data suggest that risky injecting and risky sex practices have declined, as have overdoses. Furthermore, field experience shows how to work in small, tight-knit communities, involving family members, sex workers, and many populations that routinely are shunned and punished in the former Soviet countries.

The Cross-Border HIV Prevention Project for IDUs in Southern China and Northern Vietnam, launched in 2002, provides peer education and distributes needles and syringes to people who inject drugs (PWID) in the South China-Vietnam border region, where injection drug use drives HIV transmission. The authors report on an eight-year study of the project, one of the longest studies of HIV prevention efforts in Asia among PWID. The study used 26 waves of serial cross-sectional surveys of PWID living near project sites in the region, as well as interviews and HIV testing, with the objective of determining change over time in HIV risk behaviors and in HIV incidence and prevalence. Analysis of the data revealed statistically significant decreases in self-reported drug-related risk behaviors (i.e., sharing drugs and injection equipment in different ways). Furthermore, HIV prevalence dropped sharply in provinces with Cross-Border Project interventions, and HIV incidence declined significantly through the 36- to 48-month period; some rebound in incidence occurred later, but again declined significantly through 96 months. While it is not possible to directly link these results to Cross-Border Project activities, the authors write that the consistency in the trends they uncovered across primary outcomes provides strong support for an intervention effect.

This editorial discusses eight articles outlining important developments in the field of injecting drug use and HIV, including advances in HIV prevention science, combination prevention and treatment as prevention, syringe design, challenges to scale-up and coverage, criminalization of drug use, and co-morbidities with hepatitis and tuberculosis. The first article discusses recent science and the implications for combination prevention for people who use drugs (PWID) and stresses that existing interventions such as needle and syringe programs, opioid substitution therapy, voluntary counseling and testing, and linkage to care are still some of the most cost-effective and efficient interventions for resource-limited settings. The second article examines some of the barriers to participation in HIV biomedical prevention trials and adherence issues among women who use drugs. Several of the other articles discuss such issues as ethnic and racial disparities within the HIV epidemic and their implications for prevention among PWID; the benefits of scaling up combination prevention interventions and treatment for PWID; the role of institutional and structural barriers, including criminalization of drug use; and the importance of treating co-morbidities endemic to PWID. According to the authors, all of the articles highlight the need for an increased evidence base of effective interventions for PWID, increased access to both prevention and care for PWID, and strategies to decrease barriers to accessing services, such as criminalization of PWID.

This comprehensive guide to HIV and drug use, written in clear, accessible language, aims to support community-based harm reduction and HIV programs, with a focus on developing and transitional countries. It thoroughly explains the issues of drug use, HIV, and health, and covers programs for special populations—women, children and young people, and prisoners—in a separate section. It spells out approaches to harm reduction, including community mobilization and gender-sensitive programming, and highlights the importance of involving all stakeholders, including people who use drugs, in programming. The guide describes in detail the HIV/AIDS Alliance good practice standards and spells out the key characteristics of effective programs.

This guide explains the rationale for including nine different evidence-based interventions in a comprehensive package of HIV prevention, treatment, and care for IDUs. Recommended interventions include harm reduction measures, HIV testing, counseling and treatment, and prevention and treatment of STIs, viral hepatitis, and tuberculosis. Frameworks are given for each recommended intervention. A checklist offers guided assessment of the availability, coverage, and quality of each intervention.

This highly detailed but easy to use document comprehensively explains the best practice guidelines for MAT of opioid addiction. There are chapters on the pharmacology and clinical pharmacotherapy of medication, the screening and assessment of potential candidates for treatment, and how to match patients with appropriate treatment options. The practicalities of providing MAT, from phases of treatment to maximizing patient retention, are covered. There are specific guidelines on the medical problems and co-occurring disorders typically seen in opioid addicted patients, as well as chapters on treating patients with multiple substance use and treating opioid addiction during pregnancy. The guide also covers administrative considerations such as staffing and program evaluation.

This training package is for workshops orienting and training public health policymakers, program developers, program managers, implementers, and field workers on IDU outreach for preventing HIV transmission. The training package has four workshop modules. Orientation to Outreach among IDUs provides evidence for the effectiveness of outreach programs and assists decision makers in introducing and developing such programs. Developing Outreach Programs for HIV Prevention among IDUs provides assistance to individuals interested or involved in developing outreach programs. Managing Outreach Programs among IDUs is for those who have never managed an outreach program, but can also be used as additional training for current managers and outreach field supervisors. Core Skills in Outreach among IDUs is designed for initial training of outreach workers or as a resource for ongoing training and revision among experienced outreach workers.

This questionnaire measures the extent and nature of sharing needles, syringes, and other injecting equipment to assess levels of injecting risk behavior. It identifies different sharing practices and can be used for different types of IDUs. It can be used to assess need and target interventions. In the context of an appropriate research design, it can be used to help assess the impact of prevention services such as needle and syringe distribution schemes, publicity campaigns, peer education, and drug treatment programs. The questionnaire covers the direct sharing of needles and syringes, as well as sharing ancillary equipment (indirect sharing). It takes about five minutes to complete.