The evidence is clear, Eastern European and Central Asian countries should adopt opioid maintenance therapy and needle exchanges to curb HIV and Hep C outbreaks, says Michel Kazatchkine

For many years, evidence has shown the effectiveness of opioid maintenance therapy in the treatment of opioid dependence and the effectiveness of opioid maintenance therapy and needle syringe programmes in preventing HIV infection among people who inject drugs. [1,2] Recent evidence shows that both opioid maintenance therapy and needle syringe programmes can also prevent people who inject drugs from getting hepatitis C. [3]

The spread of HIV/AIDS among people who inject drugs and their partners has been contained in Western Europe, Australia, Canada, China and other countries of Asia, because interventions such as clean needle exchange and opioid maintenance therapy programmes became mainstream government health policy sanctioned by the World Health Organisation. 

Harm reduction is receiving increasing attention from policy makers across Sub-Saharan Africa. Unsafe drug injection is recognized as an underestimated component in preventing HIV and hepatitis C infection in vulnerable groups in high prevalence settings across sub-Saharan Africa and Asia. 

However, in Eastern Europe and central Asia, harm reduction policies are conspicuous by their absence, even though there are high rates of HIV and hepatitis C infection.  

The absence of harm reduction policies is conspicuous as rates of injecting drug use are persistently high in Eastern Europe and Central Asia, approximately four times that of the global average, although the trend is decreasing. [4] Heroin continues to be the dominant injected drug, but many countries in the regions are seeing increasing rates of injected stimulant use (metamphetamines). [5] 

People who inject drugs or have injected drugs at some point in the past continue to represent 40–50% of newly reported HIV diagnoses across Eastern Europe and central Asian region. [6]

Around 25% of the estimated 3.1 million people who inject drugs in the region are infected with HIV and 65% test positive for hepatitis C. [7]

Co-morbidities such as HIV-TB and HIV-hepatitis C co-infection have now become normalised in countries like the Russian Federation which accounts for around 80% of the region ‘s HIV infections. [8] 

The uptake of antiretroviral therapy (ART) has been increasing in the region in the past few years as the price of medicines has been decreasing and antiretroviral regimens have been simplified and standardised. Yet, only 35% of the estimated number of people living with HIV in the region currently access antiretroviral treatment, and that figure is only close to 10% for people who inject drugs. [9] Figures are much lower when it comes to treatment of hepatitis C with direct antiviral agents (DAAs). Other than the extensive hepatitis programme that is in place in Georgia, still less than 5% of patients access curative hepatitis C treatment across the region. [10]

Further evidence now shows that opioid maintenance therapy and needle syringe programmes are effective in preventing the acquisition of hepatitis C in people who inject drugs. A meta-analysis of data published in the last eighteen months shows that opioid maintenance therapy reduces the risk of hepatitis acquisition by 50% among people who inject drugs, while opioid maintenance therapy and needle syringe programmes reduce the risk of acquiring hepatitis C. [11]

The effectiveness of opioid maintenance therapy and needle syringe programmes in reducing the risk of HIV infection among people who inject drugs has allowed Western European countries to reduce the proportion of people who inject drugs among new HIV infections to less than 1-2%. Opioid maintenance therapy has further allowed a large number of people to regain normal family and working lives in the society. 

The Russian Federation accounts for nearly 80% of all new HIV infections in the region and modelling shows the potential benefit of introducing and scaling up these interventions in that country. [12] 

It is estimated that extending access to opioid maintenance therapy and needle syringe programmes to 50% of people who inject drugs, together with access to antiretroviral therapy for those in need, would result in a 53% and 76% reduction in the number of new infections within ten years in Omsk and Ekaterinburg, two cities with severe HIV epidemics associated with unsafe drug injection. [13,14] 

The epidemics of HIV and hepatitis among people who inject drugs and their partners continue to severely affect the Eastern European and central Asian region. Yet, we have evidence that opioid maintenance therapy and needle syringe programmes are effective at prevention. It is the right time for governments in the region to review the evidence, review their policies, and reign in their HIV and hepatitis epidemics. 

Michel Kazatchkine is the Special Advisor to the Joint United Nations Program on AIDS (UNAIDS) in Eastern Europe and Central Asia
Competing interests: None declared.

References

1. WHO. https://www.who.int/substance_abuse/activities/treatment_opioid_dependence/en/
2. Wodak A, McLeod L. The role of harm reduction in controlling HIV among injecting drug users. AIDS 2008; S2:s81-s92.
3. Platt L, Minozzi S, Reed J, et al. Needle Syringe programs and Opioid Substitution Therapy for preventing hepatitis C transmission in people who inject drugs.  Cochrane database of systematic reviews 2017; 9: CD012021.
4. UNAIDS. 2016. Prevention gap report. http://www.unaids.org/sites/default/files/media_asset/2016-prebetion-gap-report_en.pdf 
5. Degenhardt L, Peacock A, Colledge 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; 5:e1192-207.
6. UNODC. World drug report. 2018. https://www.unodc.org/wdr2018.
7. WHO. World hepatitis report. 2017. https://www.who.int/hepatitis/publications/global-hepatitis-report2017/en 
8. UNAIDS. Global AIDS update: miles to go: closing gaps, breaking barriers, righting injustices 2018. hhtp://www.unaids.org/sites/default/files/media_asset/miles-to-goen.pdf
9. UNAIDS. 2016. Prevention gap report. http://www.unaids.org/sites/default/files/media_asset/2016-prebetion-gap-report_en.pdf 
10. UNAIDS. Global AIDS update: miles to go: closing gaps, breaking barriers, righting injustices 2018. hhtp://www.unaids.org/sites/default/files/media_asset/miles-to-goen.pdf
11. WHO. World hepatitis report. 2017. https://www.who.int/hepatitis/publications/global-hepatitis-report2017/en
12. Cepeda JA, Eritsyan K, Lyubimova A, et al. Potential impact of implementing and scaling up harm reduction and antiretroviral therapy on HIV prevalence and mortality and overdose deaths among people who inject drugs in two Russian cities: a modelling study. Lancet HIV 2018; 5: e78-87.
13. Cepeda JA, Eritsyan K, Lyubimova A, et al. Potential impact of implementing and scaling up harm reduction and antiretroviral therapy on HIV prevalence and mortality and overdose deaths among people who inject drugs in two Russian cities: a modelling study. Lancet HIV 2018; 5: e78-87.
14. Bekker LG, Alleyne G, Baral S, et al. Advancing global health and strengthening the HIV response in the era of sustainable development goals: the international AIDS Society-Lancet commission. 2018;18:7-53.