Jarlais, Don C.D.a; Cooper, Hannah L.F.b; Bramson, Heidia; Deren, Sherryc; Hatzakis, Angelosd; Hagan, Hollyc
In the most recent estimate, there are 16 million persons who inject drugs (PWIDs) throughout the world, of whom 3 million are HIV seropositive . In many countries, substantial proportions of IDUs are members of racial/ethnic/nationality minority groups, though there has not yet been a systematic review of the proportion of ethnic minority PWID. Ethnic minority PWID often have higher rates of HIV infection than do ethnic majority PWID in the same country. These disparities in HIV infection can create multiple serious problems for controlling HIV epidemics among PWID. Higher rates of HIV/AIDS among ethnic minority PWID can lead to the following:
1. Multiple reinforcing sources of stigmatization, including stigmatization based on ethnic minority status, injecting drug use and HIV/AIDS.
2. An unwillingness of public officials to provide services to stigmatized PWID.
3. Reluctance among PWID at risk for HIV/AIDS to utilized existing services because of fear of stigmatization.
4. Because most PWID are sexually active, high rates of HIV/AIDS among ethnic minority PWID may lead to high rates of sexual transmission of HIV within the ethnic minority group.
In this article, we will first review current knowledge of ethnic disparities in HIV prevalence among PWID, and then consider prospects for reducing these disparities within the contexts of the changing international epidemiology of injecting drug use, the changing international epidemiology of HIV among PWID, the uneven progress in reducing HIV among PWID, the potential for evidence-based HIV prevention programming to eliminate new HIV infections among PWID, and current fiscal and policy issues relevant to possible elimination of new HIV infections among PWID.
ETHNIC DISPARITIES IN HIV INFECTION AMONG PERSONS WHO INJECT DRUGS
We are conducting a systematic review and meta-analysis of racial/ethnic disparities in HIV prevalence among PWID. The review utilizes standard methods for meta-analysis and follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Potential studies were identified through electronic databases (PubMed, EMBASE, PsychInfo, Soc Abstracts), tables of contents of relevant journals, gray literature and consultation with experts in the field. To be eligible for inclusion in the meta-analysis, a research report had to measure HIV prevalence with laboratory testing (not self-report), have a sample recruited from a setting other than an HIV treatment location (where all patients would be expected to be HIV seropositive) or present data separately for injecting drug users, and report HIV prevalence by racial/ethnic group status. Data were abstracted from eligible reports with a standard coding form using the racial/ethnic group categories included in the report and classified as to whether the group was a minority group or was the majority group within the country in which the study was conducted. Odds ratios (ORs) were calculated for HIV prevalence among each racial/ethnic minority group and contrasted with the national racial/ethnic majority group in each country.
Whereas this review has not yet been completed, the first analyses do permit several conclusions with respect to ethnic disparities in HIV prevalence among PWID. As of January 2012, 72 studies met inclusion criteria from over 35 000 screened research reports. These reports generated 144 minority group/majority group comparisons (ORs for HIV prevalence in minority group members compared with HIV prevalence in majority group members). Many reports contained more than one minority group among their patients and generated multiple minority/majority group comparisons.
Overall, minority group PWID were much more likely to be HIV seropositive than majority group PWID. In 75 of the comparisons, the minority group had a significantly higher HIV prevalence than the majority group [lower bound of 95% confidence interval (CI) for ORs greater than 1.0]. In 66 of the studies, there was not a significant difference in HIV prevalence between the minority and majority groups (95% CI for the OR included 1.0) and in only three reports did the majority group have a significantly higher HIV prevalence (upper bound for 95% CI was less than 1.0). The weighted summary OR across the 144 comparisons was 2.06, indicating that minority group members were twice as likely to be HIV seropositive as majority group members across all of the studies. The ORs were particularly high in the USA and China.
Within the overall tendency for ethnic minority group PWID to have higher HIV prevalence rates, there were also variations in HIV prevalence among the minority/majority groups. The interquartile range for the ORs ranged between 1.25 and 3.28. I squared, a measure of heterogeneity among the studies, was 79%. (I squared values above 50% are generally considered to indicate a high degree of heterogeneity in meta-analyses. The log ORs formed an approximate Gaussian distribution. These results suggest important differences in social determinants of HIV risk in different countries. Efforts to ameliorate existing disparities and to prevent the emergence of new disparities will thus require sophisticated epidemiologic knowledge of the local situation (‘know your epidemic’), as well as large-scale implementation of evidence-based programs that are readily accessible to ethnic minority PWID. Efforts to address ethnic disparities in HIV infection among PWID will also need to consider the changing epidemiology of injecting drug use itself and of the changing epidemiology of HIV among PWID.
CURRENT EPIDEMIOLOGY OF HIV INJECTING DRUG USE
Although the injection of illicit narcotics was once so geographically concentrated that it was termed ‘the American disease’ , over the last several decades it has become a truly international problem. Aceijas et al. noted that injecting drug use had been reported in 130 countries during the period 1998–2005, and estimated that there were 13.2 million PWID. In 2008, Mathers et al. noted that injecting drug use had been reported in 148 countries and estimated that there are 15.9 million PWID worldwide (range 11.0–21.2 million). More recent estimates indicate that injection drug use has been identified in 151 countries . The increase in drug injection has been particularly pronounced in Africa .
Trends in drugs injected
Increases in the injection of opioids other than heroin have been reported in Australia, Canada, Europe, and the USA [6▪,7▪▪,8]. Many of these are prescription opioids, including morphine, fentanyl, codeine, oxycodone and hydrocodone, or substitution drugs used in treating heroin addiction (e.g., methadone, buprenorphine [7▪▪]). This shift may be attributed in part to declines in the production of opium in Afghanistan.
Spread of amphetamine type stimulants use
There has been a large increase in the use of amphetamine type stimulants (ATS) in many countries, particularly in Southeast Asia . The extent to which use of ATS will increase HIV transmission has not yet been determined. Certainly injection of ATS poses a risk for transmission through shared needles and syringes. Amphetamine use has also been associated with increased sexual risk behavior among certain groups such as MSM [10▪]. There is great variation in the patterns of ATS use, however, and most ATS is probably not associated with increased risk of HIV transmission.
Transitions to noninjecting drug use
Against this background of increases in injecting drug use, it is important to note that there have also been individual and group level transitions from injecting to noninjecting drug use. These have been reported in the USA , Spain , The Netherlands , Brazil , and Malaysia . The reasons why some injectors change to noninjecting drug use and the mechanisms they utilize to avoid relapsing back to injecting are not well understood, but these transitions could have considerable potential for reducing the transmission of blood-borne viruses. At the very least they would reduce the number of persons at risk for transmitting HIV and HCV through sharing of needles and syringes.
Developments in low HIV seroprevalence countries
There are a moderately large number of areas wherein HIV has entered the drug injecting population, but the prevalence has remained at 5% or less with large-scale combined prevention programming. Examples include Sydney, Australia; Glasgow, Scotland; Lund, Sweden; Tacoma, USA; and Toronto, Canada .
HIV prevalence had been quite low in Greece, but an outbreak of HIV transmission recently occurred in Greece following problems in coverage of HIV prevention services . The numbers of newly diagnosed drug injectors with HIV increased from nine to 19 per year to 113 during January 1–July 31, 2011. Response to the outbreak has included epidemiological and phylogenetic analyses and early warning reports [18▪▪,19▪]. Drug treatment was greatly increased. Plans were developed for rapid action and research concerning the Greek outbreak  as well as similar outbreaks in Bulgaria and Romania [20▪▪]. A possible association was reported with PWID switching to injecting amphetamine type stimulants, including synthetic cathinones, following a severe heroin shortage. Greek authorities immediately arranged for large numbers of syringes to fight the outbreak. Proposals were submitted to European and US funders to support this work. On request of the European Commission a rapid assessment of risks of further HIV outbreaks among PWID in Greece, Romania and other European Union (EU) countries was carried out and published by European Monitoring Centre for Drugs and Drug Addiction/European Centre for Disease Prevention and Control [20▪▪]. The outbreaks in Greece and Romania suggest the possibility of similar outbreaks in some other EU countries, given increases in hepatitis C infection (an indicator of injection risk) and low prevention coverage (opioid substitution treatment, needle and syringe programs) .
Developments in high HIV seroprevalence countries
There are also countries that have experienced high HIV seroprevalence among PWID. In 20 countries, seroprevalence among PWID reached 20% or higher . Data on the history of the HIV/AIDS epidemics in 14 of these countries are presented in Table 1. (Data abstracted from Des Jarlais et al.[22▪▪]). The HIV/AIDS data are primarily from national health departments. Newly reported cases of HIV among PWID were used for countries in which these data were available; newly reported cases of AIDS were used for countries in which HIV data were not available.
In many of these countries, combined prevention programming was implemented and HIV/AIDS among PWID has clearly been dramatically reduced – with reductions of 90% or more from the year with the peak number of HIV or AIDS cases to the present.
The epidemic is clearly continuing in some high HIV seroprevalence countries. China and Russia experienced their greatest number of HIV/AIDS cases among PWID in 2009. China is still in the process of scaling up interventions , but, as discussed below, implementation has stalled in Russia.
The continued transmission of HIV in many high prevalence epidemics and HIV outbreaks in formerly low seroprevalence areas means that existing ethnic disparities in the high prevalence epidemics are likely to persist and that new disparities may arise in areas where outbreaks occur.
As concern continues for the growing numbers of PWID and for their contribution to generalized epidemics, attention is increasingly shifting to the levels of coverage of evidence-based HIV prevention and treatment services for PWID. Attention has particularly focused in low and middle income countries (LMICs), and has included increased attention to the monitoring and reporting of prevention and treatment efforts.
In 2008, the Joint UN Programme on HIV/AIDS, UN Office on Drugs and Crime, and WHO provided guidance for a comprehensive set of interventions for the prevention, treatment and care of PWID . [Note that these Technical Guidelines are currently being revised, (Verster A, personal communication)]. A systematic literature review was conducted to assess coverage for these services [25▪▪], including needle and syringe programs (NSPs); opioid substitution therapy (OST) and other drug treatment; HIV testing and counseling; antiretroviral therapy; and distribution of condoms. By 2009, only about half of all countries reporting PWID had implemented NSPs (82) or OST (70). While this represented a modest increase since early 2008, there was substantial variation in coverage between countries and regions. For example, sub-Saharan Africa with 01 needle-syringes per PWID per year had the lowest rates, and Australasia, with 202 syringes per PWID per year, had the highest. Worldwide, an estimated 2 needles/syringes were distributed per PWID per month; there were eight recipients of OST per 100 PWID; and four PWID received ART per 100 HIV seropositive PWID [25▪▪]. Overall this review concluded that coverage was poor in most countries, and insufficient for preventing new HIV epidemics or impacting the existing HIV epidemics. Furthermore, in many cases it was difficult to generate estimates because surveillance data were unavailable; in these cases reviewers used gray literature, or estimates from nongovernmental organizations and ministries of health whenever possible.
Local area coverage
Although it is important to examine coverage at the national level, it is also important to consider the effects of varying coverage at a local level. Spatial access to NSPs also shapes vulnerability to HIV and HCV within small geographic areas, such as neighborhoods [26▪▪,27,28]. Cooper et al.[26▪▪] found that PWID living in New York City health districts with better spatial access to NSPs, or with better spatial access to pharmacies selling syringes without a prescription, were less likely to report recent receptive syringe sharing (RSS). Spatial access to NSPs distributing higher volumes of syringes was also associated with less RSS . Notably, the relationship between spatial access to NSPs and RSS was attenuated in health districts with elevated drug-related arrest rates, suggesting that enforcement tactics targeting PWID and other drug users may undermine harm reduction efforts ; several other studies echo these findings [31–34].
At present we do not have an in-depth understanding of coverage needs for the prevention of HIV transmission among PWID at either a national or a local level. And we do not have a good understanding of coverage need for ethnic minority PWID. As ethnic minority PWID often have higher HIV prevalence, they presumably need higher coverage for all prevention, treatment and care services. Planning prevention and care services for ethnic minority PWID in resource limited settings will be a complex epidemiological and policy issue.
FINANCIAL AND POLICY ISSUES
Combined behavior change approaches to HIV prevention among PWID, particularly NSP and OST, have been quite effective in many countries. If large-scale implementation of additional biomedical interventions such as ‘treatment as prevention’ and PrEP were to occur, it is quite likely that the incidence of drug-injecting related HIV incidence could be reduced to extremely low levels, more than 0.5/100 person-years, and an R0 less than 1.0 could be achieved. Unfortunately, the immediate prospects for public-health scale programs for prevention and treatment of HIV among PWID seem to be diminishing. The current global economic problems have led to reductions in international aid, to the point wherein the Global Fund had to cancel its Round 11 grants. (For a discussion of the operational and fund-raising issues behind the cancellation of Round 11 see Laurie Garrett ).
The US federal government recently reinstituted its ban on the use of federal monies to support syringe distribution. This applies to the use of US federal funds both domestically and internationally. As the US President's Emergency Program for AIDS Relief (PEPFAR) is the largest single-nation program for AIDS prevention, care and treatment, the restriction of potential PEPFAR funding for syringe distribution must be considered a potentially important impediment to HIV prevention for PWID.
The Russian Federation has recently rejected ‘Western’ approaches to addressing HIV/AIDS among PWID, particularly opiate substitution therapy [36,37▪,38]. This situation places the estimated one million and drug injectors in Russia at high risk for continued transmission of HIV.
HIV prevention and treatment for PWID are being scaled up in a number of countries, including China, Vietnam, and Malaysia. These countries, however, also utilize centers in which PWID are detained without judicial due process and without receiving any evidence-based treatment for dependence . The threat of being detained in such centers can also undermine the utilization of evidence-based interventions by PWID.
Given their multiple stigmatizations, the negative impacts of the financial and policy issues are likely to disproportionately impact ethnic minority PWID.
There has also been continuing movement toward policies based on scientific evidence and human rights. A notable development was the Vienna Declaration issued in conjunction with the Vienna International Conference on AIDS . The Declaration notes that the War on Drugs approach has not eliminated illicit drug use, but has increased the adverse social and individual consequences of drug use, and calls for an evidence-based human rights approach to public health problems related to psychoactive drug use. Addressing ethnic disparities in disease is fundamental to a human rights approach to public health.
SEXUAL TRANSMISSION OF HIV AMONG AND FROM PERSONS WHO INJECT DRUGS
Most persons who inject drugs are also sexually active, so if HIV reaches high prevalence in a population of PWID, there is the possibility that sexual transmission from PWID may initiate a heterosexual epidemic. As noted in the introduction, higher HIV prevalence among ethnic minority PWID may lead to increased risk of sexual transmission of HIV in minority communities. Des Jarlais and colleagues recently examined injection drug use (IDU) and heterosexual epidemics in countries in which HIV prevalence had reached more than 20% [22▪▪]. Given the observational nature of the data, it was not possible to prove that an IDU-concentrated epidemic initiated a heterosexual epidemic, but it was possible to identify countries in which it was ‘highly unlikely’ that the IDU epidemic initiated a heterosexual epidemic (France, Italy, Scotland, Spain, Thailand) versus countries in which it was ‘plausible’ that the IDU epidemic initiated a heterosexual epidemic (Argentina, Brazil, China, Indonesia, The Netherlands, Ukraine, Estonia, Russia and Vietnam). Characteristics that distinguished between the ‘highly unlikely’ versus ‘plausible’ initiation of a heterosexual epidemic were national income (high vs. low/middle), the time between peak year of new HIV/AIDS cases in PWID to year in which heterosexual cases exceeded PWID cases (1–2 versus 6–10 years), and whether high incidence persisted among PWID after the peak year of new cases among PWID (rapid decline in new cases among PWID versus persistence of high HIV/AIDS incidence among PWID). Rapid implementation of large-scale programs to reduce HIV incidence among people who inject drugs may protect against initiation of heterosexual epidemics.
HEPATITIS C VIRUS AMONG PERSONS WHO INJECT DRUGS
Both HIV and hepatitis C virus (HCV) are transmitted through sharing of drug injection equipment. As with HIV, ethnic disparities have been observed with HCV infection among PWID. The disparities have not been observed as frequently as with HIV, but when differences have been observed, ethnic minority group members had higher HCV prevalence . HIV coinfection increases HCV disease progression, and the great majority of HIV seropositive PWID are also infected with HCV. A recent systematic review found reports on HCV antibody prevalence in PWID in 77 countries [42▪▪]. Using midpoint estimates, country-specific prevalence ranged from 10 to 90%, although in 25 countries prevalence was between 60 and 80%, and in 12 it exceeded 80%. The total number of anti-HCV positive PWID worldwide was estimated to be 10 million. A systematic review and meta-regression of time to acquisition of HCV infection in PWID also showed that, in high-income countries, HCV prevalence declined after 1995, corresponding to a period when harm reduction services expanded in these regions of the world . Other recent studies have shown that combination prevention strategies – substance use treatment and access to sterile injecting equipment – is also associated with reduced likelihood of HCV seroconversion at the individual level [44▪▪,45▪]. Treatment of chronic HCV infection will benefit individual patients and will also eradicate a source of infectiousness; when treated with the new direct-acting antivirals [46▪], up to 75% of patients with genotype 1 infection may achieve a sustained virological response (SVR), in comparison to 40% SVR in those treated with the previous regimen of pegylated interferon and ribavirin [47–50]. As with substance use treatment and sterile injecting equipment, access to HCV treatment is extremely limited, and it is estimated that fewer than 5% of HCV-infected PWID in the USA and Australia receive HCV treatment [51–53].
Ethnic disparities in HIV infection among PWID exist in many countries; overall, ethnic minority PWID are twice as likely to be HIV seropositive as ethnic majority PWID from the same area. There is, however, great variation in the disparities, so that efforts to reduce disparities will need to be adapted to the local situation. Efforts to reduce these disparities will also need to be adapted to the changing epidemiology of drug injecting and of HIV among PWID.
Public health scale implementation of existing technologies should be able to control and possibly eliminate needle-borne HIV transmission among PWID, including among ethnic minority PWID. This will require resolving the financial and policy problems that are currently the largest barrier to preventing HIV transmission among PWID globally. Unfortunately, as a multiply stigmatized group, ethnic minority PWID are likely to suffer disproportionately from the financial and policy problems. Addressing ethnic disparities in HIV infection among PWID will be a fundamental issue for the emerging human rights basis for a public health perspective toward psychoactive drug use.
Conflicts of interest
This study is funded by the National Institute of Drug Abuse Grant # 5R01DA024612 and National Institute of Allergy and Infectious Diseases Grant# 1R01AI083035.
The authors have no conflicts of interest.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
▪ of special interest
▪▪ of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 380–381).
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