Urgency of global access to ARV treatment for IV drug users

Mauro Guarinieri, for HIV i-Base

A week-long conference is definitely a good thing in the fight against AIDS but it will count for almost nothing if it is not followed up by concrete measures and action.

Since the last global AIDS gathering in Barcelona in 2002 6 million people have died and 10 million have been newly infected, so the question now is: “What will the follow up be?”

Months before the conference kicked off activists were saying that Bangkok had the potential to become a a real turning point in focusing the right kind of attention on drug use and HIV/AIDS issues. They were saying that discussion of HIV control in developing countries usually pays insufficient attention to injecting drug use (IDU). Yet half the population of the world lives in developing countries within a few hours flight from Bangkok, in a region where HIV infection is dominated by the sharing of injecting equipment.

UNAIDS estimates that injecting drug use accounts for 10% of annual HIV infections worldwide, as many as one in three new HIV infections outside Africa, and is the driving force behind the world’s fastest growing epidemics. In Russia, as many as 1 million people have been infected with HIV in less than 10 years, with over 80% of infections being among injecting drug users (IDUs). All the countries of Central Asia and many in Southeast Asia and the Southern Cone of Latin America report that IDUs account for a majority of HIV infections or a rapidly growing share of total cases.

A high prevalence of HIV is now found among IDUs in Myanmar, Vietnam, China, Thailand, Malaysia, Indonesia, Nepal and Iran. In several of these countries, authorities are now reporting that over 60% of IDUs who have been tested are HIV positive. China alone is now estimated to have almost 900,000 injecting drug users, and more than 60% of the country’s 1 million estimated infections are among IDUs. There are also large pockets of HIV-positive IDUs in other populous Asian countries, such as India and Pakistan.

Fuelled by economic, social and political constraints, IDU continues to proliferate in this region as it does in many other parts of the world and what is more frightening is that HIV continues to spread among and from IDUs much more rapidly than the adoption and expansion of effective harm reduction interventions.

The major obstacle remains an entrenched commitment to an unbalanced drug policy heavily reliant on supply control, reinforced by a common but unwarranted fear that expansion of drug policies to include pragmatic harm reduction strategies will conflict with efforts to control the supply of and demand for illicit drugs.

Before the conference, activists from around the globe denounced the fact that drug users still represent a minority of those receiving ARV and called on the international community to ensure the inclusion of injecting drug users in the scale-up of antiretroviral therapy. More specifically, they called on the World Health Organisation (WHO) to ensure the inclusion of injecting drug users in its plan to treat 3 million people by 2005.

Following up a specific proposal made by over 200 drug users, people living with HIV/AIDS, and advocates from around the globe, to include methadone and buprenorphine into the List of Essential Drugs, Dr Andrew Ball, Manager of Regional and Country Support of the WHO HIV/AIDS Department, said during the conference: “The WHO fully recognises the overwhelming evidence that methadone and buprenorphine are highly effective treatments for drug dependence and prevention of HIV/AIDS, and has undertaken an extensive review of the effectiveness of methadone in HIV/AIDS prevention and care.” He added: “An independent expert committee is considering including methadone on the WHO Essential Drugs List,” during a press conference organised by the Open Society Institute, the European AIDS Treatment Group, the Russian Community of People Living with HIV/AIDS and the Thai Drug Users Network.

He said, however, it was not up to the agency to make drugs like methadone or buprenorphine widely available to the public. But the WHO supports the drugs being added to the Essential Drugs List, which is supervised by an independent committee.

The same statement was made by Dr Jim Kim, Director of the WHO’s HIV/AIDS programme, at the end of a colourful demonstration comprising people living with HIV, drug users and sex workers, who called for action and accountability to stop the spread of AIDS before the conference opening. Kim emphasised that experience in many countries had shown that criminalisation of drug use only escalated the spread of AIDS.

Fearing the International Aids Conference was just another talk shop with empty promises, more than 1,500 people from all over the world joined the march, clutching banners and wearing various styles of slogan-bearing T-shirts to voice their demand to be included in the action plans. For Thais, the major demands – which were passed to Prime Minister Thaksin Shinawatra – included ensuring sustainable coverage for the cost of anti-retroviral therapy and the immediate end of Thaksin‘s all-out war on drugs, in which more than 2,500 drug users were killed under questionable circumstances.

An estimated 100,000 to 250,000 people in Thailand inject heroin, even though methamphetamine pills have overtaken heroin as the country’s drug of choice. HIV prevalence among the country’s heroin users has stood at 40% or more since the late 1980s, in contrast to the declining rates among others at high risk. Drug users face limited treatment options and regular abuse by police, including beatings, false arrest and forced confessions. The zero-tolerance Thai campaign’s only effect was to drive intravenous drug users, who reportedly make up about 40 per cent of Thailand’s Aids patients, underground.

The Thai government crackdown began in February 2003 for the official reason of curbing the trade in methamphetamine tablets. Within 3 months, an estimated 2,275 drug suspects were shot dead. Scores of alleged drug dealers were placed on poorly prepared government “blacklists” and ordered to report to the police and many were shot by unknown gunmen shortly after leaving the police station. In addition to almost 3,000 unexplained deaths, thousands had been forced into drug treatment in military-style boot camps.

Not surprisingly Prime Minister Thaksin Shinawatra’s controversial war on drugs came back to haunt him during the opening ceremony. When Thaksin insisted in his speech that his government no longer treated drug users as criminals but as patients, demonstrators and hecklers reminded him of the controversial campaign that was condemned by the international community, including the United Nations. “Thaksin Lies” read one sign that went up in the packed auditorium. Activists reacted in uproar when their representative, Paisan Suwannawong, former heroin addict and chairman of the Thai Treatment Action Group, was designated as the last speaker at the opening ceremony of the Conference. By the time he reached the podium, Prime Minister Thaksin and UN Secretary General Kofi Annan, had already left the hall.

In contrast to claims made by conference organisers that people living with HIV/AIDS had been given wider access than ever before, activists said they continued to be ignored and even discriminated against by people in power. “What hypocrisy,” said Paisan, also leader of the Thai Drug Users Network. “Thaksin said in his speech that he cares and wants to help drug users, so why didn’t he stay to listen to me.”

All through the conference, activists called for a worldwide reversal of public opinion on injecting drugs use. They said in many countries drug users have set up their own organisations that work to reduce the spread of infectious diseases, to decrease discrimination against drug users in society, and to improve medical treatment of all sorts for drug users.

At the eve of the conference, the International Harm Reduction Programme (IHRD) of the Open Society Institute released a report detailing successful efforts to offer drug users antiretroviral treatment (ARV) and the dangers of failing to do so. “The common assertion that drug users cannot comply with treatment represents a failure of vision by AIDS programme administrators, not a description of reality,” said IHRD programme officer Konstantin Lezhentsev, noting that the report described successful efforts to offer ARVs to IDUs in Brazil, Argentina, and a number of urban settings in Western Europe and the US. “The question is whether governments and healthcare systems will step up to their responsibility to meet the specific needs of this group, or continue to simply deny treatment to drug-users based on the myths that are based more on prejudice and discrimination than on healthcare and human rights principles.”

Activists underlined the importance of shifting both from the medical model – according to which IDUs are sick, they cannot adhere to treatment, and they have worse clinical outcomes – and the criminal model – by which they need to be charged and incarcerated, since they perpetuate a cycle of criminality that goes beyond just drug use. It is necessary to admit that when given proper access to healthcare, IDUs can adhere to treatment and have comparable clinical outcomes to other patient populations. It is time to accept that criminality is not caused by drug use but by the same criminal system. Eliminating repressive drug laws and stopping widespread propaganda that blames IDUs for social and economic evils of all descriptions, and halting government-sponsored campaigns that murder them, can only support the functioning of IDUs in society.

Most importantly, they committed to establishing better and stronger links with drug users and harm reduction networks, noting that in most cases drug users’ organisations also work for the decriminalisation of drug use. “What once was radical has to become common sense,” said Paul Davis of Health Gap USA.

Harm reduction and HIV treatment activists have been building their capacity for the last year to arrive at this successful point. In spite of enormous challenges, involving legal, cultural, and moral dilemmas, a formidable and growing array of committed individuals and groups has now entered the battle.

They are trying to raise global awareness to the fact that no area more than drug use clearly demonstrates the bad consequences of abstinence based approaches, and that although in 7 out of the 10 UNAIDS regions (accounting for 90% of the global population) injecting drugs is considered among the most important risk factors for HIV, in many countries injecting drug users are still stigmatised, routinely excluded from treatment, and treated badly by various institutions along a continuum that has insults at one end and violent death at the other.

Unsurprisingly, exactly the same countries where discrimination creates the conditions of furtive drug injection using shared injection equipment are those where HIV prevalence among people who inject drugs is higher. This includes the United States. Despite the American impulse to tell other countries how to do it, the timing and scale of implementation of HIV prevention measures for IDUs in the USA has been anything but impressive, with at least 36% of new AIDS cases in the USA still directly or indirectly associated with injecting-drug use.

Although on 20 February, 1933, the US Congress acknowledged the failure of alcohol Prohibition, it seems that US officials have a strong incentive to maintain their faith in old paradigms even as the facts become increasingly difficult to explain within that paradigm, proving that attitudes toward drug users are often based on beliefs, misconception, moral certainty and “common sense”, rather than on medical evidence.

Evidence tells us a very different story: that drug users can do as well as anybody else and that even the poor and the homeless can adhere to ARV. Their exclusion from treatment and care has nothing to do with science. Rather, it has to do with a widespread discrimination toward active drug users.

So the only measure of both our success and our failure will be the number of lives that are saved, the adoption and implementation of evidence based policies to ensure comprehensive harm reduction approaches to prevention, care and treatment, the elimination of criminalisation, stigmatisation, and marginalisation of drug users, and a substantial reduction in the number of drug users sent to prisons.

AIDS reminds us that all transmissible diseases are rooted in social and economic life, and that respect for human rights and human dignity are paramount in responding to the epidemic. We have heard too many sad stories from Africa, where endless discussions were just an attempt to hide the real reason for not making treatment available, to let authorities do the same on injecting drug use.

Support from international organisations for equitable and comprehensive treatment for HIV-positive or at-risk drug users is growing dramatically as we can see from the UK Department for International Development, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, the World Health Organisation, and UNAIDS.

History will tell us whether their commitment to address the social, cultural, legal, and medical barriers that deprive IDUs of access to HIV treatment will result in effective changes in policies and laws. But while there are many declarations of positive intentions and good meetings taking place, it is up to us, the community, to speak out, advocate, and make our voice heard.

Mauro Guarinieri is Chair of European AIDS Treatment Group (EATG):

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