HIV Drug Resistance



Injecting Drug Use

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|Updated in April 2008 |

Technical elements

Essential elements of a comprehensive health sector response for injecting drug users include:

• Harm reduction interventions to reduce HIV transmission: including access to needle and syringe programmes NSPs (providing sterile equipment as well as their safe collection and disposal); drug dependence treatment, particularly opioid substitution therapy OST; condom programming; STI treatment, targeted information and education; and HIV testing and counselling;.

• Management of co-infections and co-morbidities: including ART; prevention and management of opportunistic infections, particularly TB; pain management and palliative care; prevention and treatment of hepatitis B and C; alcohol and other drug dependence; and depression.

• Other services: including peer outreach; integration of HIV/AIDS interventions within drug dependence and outreach services; integration of IDU issues within HIV/AIDS services.

• Supportive policy, legal and social environment: including policies that ensure equitable access to HIV services for drug users; laws that do not compromise access to drug dependence and HIV services for IDUs through criminalization and marginalization; and campaigns to reduce stigma and discrimination, particularly related to health services and workers.

This comprehensive approach needs to include outreach to both sexual and injecting partners of injecting drug users.

Operational Considerations

In supporting countries, efforts should focus on moving from small-scale pilot projects for injecting drug users to comprehensive national programmes that are fully integrated into the health sector.

The key actions to consider in implementing these interventions at country level should include:

• Advocacy: where barriers to harm reduction still exist, need intensive promotion of a public health approach to HIV prevention among drug users among national decision makers;

• Reinforcing partnerships: especially with UNODC as the lead UN agency;

• Assessment: to identify what the situation really is and where the problems are so that the interventions are based on reality;

• Policy guidance: develop and update national harm reduction policies and legislation with regard to IDU; inform politicians, influential leaders and other decision-makers about the urgent need to respond to HIV/AIDS with specific interventions for IDUs; disseminate evidence and experience (the Evidence for Action series and examples from other relevant countries); authorities should also review drug laws, law enforcement practices and the provision of health services to create an environment in which harm reduction programmes can thrive;

• Tools and guidelines: ensure adaptation of tools and guidelines in particular for the management of co-infections (including tuberculosis, hepatitis B and hepatitis C) and co-morbidities (e.g. depression) among drug users living with HIV/AIDS. HIV/AIDS issues need to be integrated into drug dependence treatment guidelines. Ensure adaptation of tools and guidelines on NSPs, OST, and other harm reduction interventions. Issues relating to the use of alcohol and other (non-injected) drugs need to be integrated into relevant tools and guidelines;

• Services: a comprehensive package of key interventions has been defined and includes needle and syringe programmes; drug dependence treatment and in particular opioid substitution therapy (OST) with methadone or buprenorphine; access to HIV testing and counselling, VCT, prevention and treatment services for STI and condom programming. These interventions should be available in the community and in closed settings and prisons;

• Capacity building: of community-based outreach organizations, workers and relevant health professionals and social service personnel who come into contact with IDUs;

• Monitoring and evaluation: selecting indicators for national HIV/AIDS programmes and for harm reduction services to assist in the monitoring of coverage, quality and effectiveness of programmes; develop a sentinel surveillance system to monitor risk behaviour and the prevalence and incidence of HIV among IDUs. Guidance ids provided from WHO, UNODC and UNAIDS at .

|Common challenges |

|Injecting drug users face a lot of discrimination. Social stigma and legal constraints make it |

|difficult to implement interventions and decrease access to and involvement in services by |

|communities. |

|The obvious question for HIV prevention among IDUs is the link between the health sector and the |

|criminal justice sector. Potential conflicts need to be addressed so that both policies can work |

|together rather than against each other. |

|Opposition to provision of opioid substitution therapy; |

|Opposition to making needles and syringes available; |

UNODC is the lead agency in the UNAIDS family with regard to drug use and HIV prevention at the global level. WHO takes the lead with regard to treatment and interventions delivered by health services. The issues are very closely related - especially where drug dependence treatment (particularly opioid substitution therapy OST) and HIV care and treatment (including ART) are mostly delivered by health services. WHO and UNODC work closely together and coordination of all efforts is essential. 

WHO is mandated to provide technical advice, including to the INCB and UNODC, on various issues, and UNODC continues to refer to WHO for technical advice. WHO will continue to maintain and establish the scientific evidence base and providing policy and technical guidance on such technical issues, such as HIV/AIDS treatment and care, opioid substation therapy and other pharmacotherapy for substance dependence, and specific harm reduction interventions, such as needle and syringe programmes.

Key Resources

Tools:

• Evidence for Action series, technical papers and policy briefs and other useful materials at

• Draft WHO/UNODC/UNAIDS Technical guide for countries to set  targets for Universal Access to HIV prevention, treatment and care for injecting drug users (IDUs) (WHO, 2007) at and

• Donoghoe MC, Verster AD, Pervilhac CE and Williams PG (2008) Setting targets for universal access to HIV prevention, treatment and care for injecting drugs users (IDUs): towards consensus and improved guidance International Journal of Drug Policy 19S:S5-S14

• the WHO Europe HIV/AIDS treatment and care protocol for IDUs at

• Policy and Programming Guide for HIV/AIDS Prevention and Care among Injecting Drug Users:

• Advocacy Guide: HIV/AIDS Prevention among Injecting Drug Users

• Training Guide for HIV Prevention Outreach to Injecting Drug Users—Workshop Manual—

• A guide to starting and managing needle and syringe programmes

Harm reduction networks:



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Facts & figures: An estimated 10% of all new HIV infections globally are related to injecting drug use, rising to over 30% if sub-Saharan Africa is excluded. Injecting drug use is the major mode of HIV transmission in eastern Europe and Central Asia where it accounts for over 80% of all HIV infections. It is also the major mode of HIV transmission in a range of countries in the Middle East, north Africa, Asia and Latin America. Explosive epidemics of HIV can occur in populations of injecting drug users where re-use and sharing of injecting equipment is common, with HIV prevalence in some IDU populations rising to over 80% within a few years.

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