Treatment training manual

7. 3 HIV and people who use drugs

“Access to HIV treatment should not be artificially restricted due to political or social constraints. Specifically there should be no categorical exclusion of injection drug users (IDUs) from any level of care. [Anyone] who meets eligibility criteria and wants treatment should receive it, including IDUs, sex workers and other populations.” – WHO, 2004

Injecting drug use as the main route of HIV transmission

In many countries, injecting drug use is still linked to the majority of new HIV infections.

These include: Russia, Ukraine, Central Asia, some countries in Eastern Europe, South East Asia, North Africa, Iran, Afghanistan, Pakistan, Nepal, Indonesia, Portugal and the Southern Cone of Latin America. In addition, drug use can also lower inhibitions and increase the risk of sexually transmitted HIV.

People at risk of becoming HIV positive through injection drug use are often among vulnerable or disadvantaged sections of society. People who inject drugs are already often socially marginalised and stigmatised by being from ethnic minorities, or from being unemployed, homeless, youth, migrants or sex workers.

Globally, an estimated 1.4 million people who inject drugs are also living with HIV. Approximately 1 in 10 new infections each year are linked to injecting drug use.

Hepatitis C virus (HCV), which is bloodbourne, is a common coinfection among people who acquired HIV from injection drug use; globally, an estimated 72% have been infected with HCV. HIV/HCV coinfection is also more prevalent among gay and bisexual men, prisoners and female sex workers.

Recreational drugs and interactions with ART

Although there are potential interactions between illicit drugs, opioid agonist therapies and some HIV drugs, there is limited research on these interactions.

This is also complicated because street drugs can be cut with other chemicals. Increasingly, drugs are being contaminated with different substances, such as xylazine (“tranq”; a veterinary tranquiliser that causes skin ulcers and abscesses), and fentanyl,  Isotonitazenean, and other very potent synthetic opioids which have led to unintentional overdose.

Although this was initially reported in North America, contaminated drugs have also been found in Asia, Europe, and Oceana.

This is also complicated because street drugs can be cut with other chemicals.

Despite the potential for drug interactions, these are mainly with earlier and less-used HIV drugs. Modern ART using integrase inhibitors plus two NRTIs is unlikely to have these interactions.

The free online Liverpool HIV Drug Interaction checker has the most detailed information about likely interactions.
hiv-druginteractions.org/checker

People who use drugs are excluded from some ART programmes

In some countries, people who use drugs are routinely excluded from access to ART.

This is because of a false belief that they are less likely to take ART and less likely to have a good response. But there is ample evidence that this is not the case. Nonetheless, some doctors still believe that ART should be withheld from people who use drugs.

Not providing ART to people who inject drugs sometimes includes those on medically prescribed opioid agonist therapy, such as methadone or buprenorphine. It can also include people who used drugs in the past.

Why it is essential for people who use drugs to access ART

In the past, some doctors thought that people who use drugs would forget to take HIV medicines. This belief that it was okay to withhold treatment was based on prejudice rather than science.

Although there is ample evidence that people who use and inject drugs can adhere and respond well to ART, some doctors are reluctant to provide it. Asking for a referral from other people who use drugs who have a good relationship with their GP is a way to avoid this.

Several studies suggest that people who use drugs can achieve high levels of adherence and that they benefit from ART just like other people with HIV. This is especially when ART is given with adherence, social and medical support.

Numerous studies have confirmed that adherence to ART is similar among  people who use and inject drugs and people who do not.

  • A meta-analysis of studies reporting ART adherence in people who inject drugs in low and middle income countries included rates that were >85% in 7/15 studies. (Feelemyer et al, 2015)
  • A meta-analysis of studies on ART uptake adherence among women who use drugs found that it was generally lower than that among men who use drugs, noting the need for gender-specific research on barriers and facilitators of ART use, and providing integrated HIV care available at flexible hours, and which includes mental health, intimate partner violence and child care services. (Glick JL et al, 2020).

Linked research

WHO. Consolidated guidelines on HIV, viral hepatitis and STI prevention, diagnosis, treatment and care for key populations.(July 2022).
Download PDF – direct link (4.1 MB)

WHO. People who inject drugs.
https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/populations/people-who-inject-drugs

Schoenberger SF et al. Police abuse and care engagement of people with HIV who inject drugs in Ukraine, Global Public Health, DOI: 10.1080/17441692.2022.2049341. (2022).
https://pubmed.ncbi.nlm.nih.gov/35343870

Guise A et al. Integrated opioid substitution therapy and HIV care: a qualitative systematic review and synthesis of client and provider experiences, AIDS Care,29:9, 1119-1128, DOI: 10.1080/09540121.2017.1300634. (2017)
https://pubmed.ncbi.nlm.nih.gov/28281354/

Kiriazova T et al. “It is easier for me to shoot up”: stigma, abandonment, and why HIV-positive drug users in Russia fail to link to HIV care, AIDS Care, 29:5,559-563, DOI: 10.1080/09540121.2016.1259451. (2017).
https://pubmed.ncbi.nlm.nih.gov/27871198

Feelemyer J et al. Adherence to antiretroviral medications among persons who inject drugs in transitional, low and middle income countries: an international systematic review. AIDS Behav. 2015 Apr;19(4):575-83. doi: 10.1007/s10461-014-0928-3.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4393761

Hajarizadeh B et al. Direct-acting antiviral treatment for hepatitis C among people who use or inject drugs: a systematic review and meta-analysis. Lancet Gastroenterology & Hepatology 3(11):754-767. (2018).
https://doi.org/10.1016/S2468-1253(18)30304-2

Rashti R, et al. Systematic review and meta-analysis of global prevalence of HBsAg and HIV and HCV antibodies among people who inject drugs and female sex workers. 2020 May 31;9(6):432. Pathogens. DOI: 10.3390/pathogens9060432.
https://www.mdpi.com/2076-0817/9/6/432

Glick JL, et al. ART uptake and adherence among women who use drugs globally: A scoping review. Drug Alcohol Depend.  2020 Aug 2. DOI:10.1016/j.drugalcdep.2020.108218.
https://pubmed.ncbi.nlm.nih.gov/32916450/

Yazdani K et al. Characterizing opioid agonist therapy uptake and factors associated with treatment retention among people with HIV in British Columbia Canada. Preventive Medicine Reports. Pre proof 29 Junes 2023.
https://doi.org/10.1016/j.pmedr.2023.102305

Last updated: 1 July 2023.