Between three to four million men and women inject drugs in Asia. Prevalence of HIV among people who inject drugs (PWID) is as high as 52% in some countries and even higher prevalence has been noted at sub-national level.
An estimated one in six people who inject drugs in Asia is infected with HIV. Over one in three PWID surveyed in Myanmar, and Thailand are HIV+ (> 30% Prevalence) and around one in five in Pakistan and Nepal (21% prevalence). The HIV prevalence among PWID continues to increase in expanding epidemics such as Indonesia where prevalence is estimated to be 52% in 2009.
According to the 2011 UNAIDS report (HIV in Asia and the Pacific: Getting to Zero), HIV epidemics can emerge even in countries where HIV prevalence was previously low. In the city of Cebu, in the the Philippines –a country that has seen more than a 20-year ‘low and slow’ HIV epidemic – HIV prevalence among people who inject drugs increased from 0.6% to 53% between 2009 and 2011.
Epidemics among PWID are also emerging in low prevalence countries, such as in Pakistan (where the HIV prevalence in PWID doubled, from 10.8% in 2005 to 20.8% in 2008). In Bangladesh prevalence among PWID in the capital city has gradually risen from 1.4% in 2000 to 7.0% in 2007. High prevalence among PWID persists even in declining epidemics in Thailand and southern India, leaving the door open to a resurgence in transmission.
While the effectiveness of needle and syringe programme (NSP) and opiod substitution treatment (OST) in HIV prevention is well documented the coverage of these life saving interventions remains low. By middle of 2011, approximately 14% of PWID were reached with needle and syringe programmes and some 5% were reached with OST. Over 300,000 people are detained in some 1,000 compulsory centres with limited or no access to interventions recommended by WHO, UNODC and UNAIDS, UNODC, ANPUD and the GFATM developed a Regional Harm Reduction Strategy for Asia and the Pacific 2010 – 2015. The UNAIDS 2011 – 2015 strategy Getting to zero calls for prevention of all new infection among people who use drugs in more than 20 focus countries, including several countries in Asia.
Getting to zero is a strategy adopted by UNAIDS in 2010. To get to zero new infections the goals for 2015 are – sexual transmission of HIV reduced by half, including among young people, men who have sex with men and transmission in the context of sex work. Vertical transmission of HIV eliminated and AIDS related maternal mortality reduced by half and all new HIV infections prevented among people who use drugs.
Mr Christian Kroll, UNODC Global Coordinator for HIV/AIDS, discussed Getting to zero at the Common Ground Session at the International Congress of AIDS in Asia and the Pacific, in Busan in August (2011). He stressed that the strategy “calls for a comprehensive, evidence based and human rights based programmes to be accessible to all people who inject drugs. These include opioid substitution programmes, sterile needle and syringe access and better alignment of law enforcement and public health approaches”.
In the developed world, Netherlands has had no new infections among injecting drugs users (IDUs), Germany has 30, Australia has 39, whereas in China there have been 30,000 infections among drug users and in Russia 10,000. Mr Kroll gave the example of Ukraine where needle and syringe programmes are estimated to cost less than $100 per HIV infection averted. Another area is antiretroviral therapy for people who use drugs and are living with HIV.
In Vietnam harm reduction efforts have produced results, for example distributing 200 needles and syringes per drug user per year had a major impact on reducing HIV incidence, not only in the drug using population but also to incidence rates in the whole population as onward transmission is reduced.
Across the region we see a number of public health concerns related to compulsory detention centres, such as absence of individual assessment for addiction severity; unnecessary institutionalization of many people who are not physically dependent on drugs; mandatory HIV testing; reports that people living with HIV in these centres, including people co-infected with TB and Hepatitis C, often do not have access to treatment; high risk of HIV, hepatitis and TB transmission among inmates and reports of high relapse rates following discharge, ranging from 60% to 100%. There are approximately 1,000 compulsory centres in East and South East Asia with more than 300,000 people detained.
UNODC has partnered with the World Bank to get hard data in specific countries and understands there are challenges in countries like Russia and Myanmar. Other difficulties include the effort to find additional resources as existing money is committed to ongoing programmes. The economic environment is testing and difficult and many developing country donors are reluctant to fund new programmes. It is good to note that the Global Fund board in Geneva is supporting zero new infections and proposals focusing on risk groups including PWID maybe submitted and will be encouraged.
Stakeholders have to increase advocacy for zero new infections among drug users. Civil society, National AIDS coordinating agencies, drug users, the World Health Organization, the World Bank, and the United Nations Office on Drugs and Crime have to lobby hard with governments and donors.
There is a need for a strong lobbying and activism from civil society to demand zero new infections. UNAIDS is calling for comprehensive, evidence informed and human-rights-based programmes accessible to all people who inject drugs (e.g. attending to harm reduction alongside demand reduction) to be scaled up. This includes programmes that reduce hepatitis co-infection, increase access to HIV treatment, and ensure legal and policy frameworks serve HIV prevention efforts.
