A COMBINATION APPROACH TO HIV PREVENTION PART 1
|
PART TITLEFIGURE 3.9 Coverage of needle–syringe programmes and opioid substitution therapy, selected countries, 2014–2018
Source: Global AIDS Monitoring, 2014–2018.
Afghanistan Albania
Armenia
Australia Austria
Azerbaijan Belgium
Bangladesh Bulgaria
Bosnia and Herzegovina
Belarus Cyprus
Czechia Spain
Estonia
Finland France
Georgia Greece
Hungary
Indonesia
India Ireland
Iran (Islamic Republic of) Italy
Kazakhstan Kenya
Kyrgyzstan
Cambodia Lithuania
Luxembourg
Latvia Morocco
Republic of Moldova Mexico
North Macedonia
Malta
Myanmar Mauritius
Malaysia
Norway
Nepal Poland
Portugal
Romania Senegal
Serbia
Slovenia Seychelles
Thailand
Tajikistan United Republic of Tanzania
Ukraine
Viet Nam
0 10 20 30 40 50 60 70 80 90 100
0 100 200 300 400 500 600 700
Percentage of people who inject drugs receiving opioid substitution therapy
Needles–syringes distributed per year per person who injects drugs 200
40
47
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Number of new HIV diagnoses Number on methadone maintenance treatment
Number of opioid-dependent people on methadone maintenance treatment New HIV diagnoses among people who inject drugs
Note: There was an outbreak of HIV among homeless synthetic cathinone users in Dublin in 2015. This is refl ected in the number of people newly diagnosed with HIV. Please see: Ireland: Country Drug Report. In: European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) [Internet]. Lisbon: EMCDDA; [date unknown] (http://www.emcdda.europa.eu/countries/drug-reports/2019/ireland/drug-related-infectious-diseases_en, accessed 16 June 2019).
8000 6000 4000 2000
Number of opioid-dependent people on methadone maintenance treatment New HIV diagnoses among people who inject drugs FIGURE 3.10 Number of opioid-dependent people on methadone maintenance treatment and new HIV diagnoses among people who inject drugs, Ireland, 2007–2017
Source: Delargy I, Crowley D, Van Hout MC. Twenty years of the methadone treatment protocol in Ireland: refl ections on the role of general practice. Harm Reduct J. 2019;16:5.
Huge gaps in harm reduction for people who inject drugs
People who use drugs have been the biggest casualties of the global war on drugs. Vilified and criminalized for decades, they have been pushed to the margins of society, harassed, imprisoned, tortured, denied services, and in some countries, summarily executed.
Amid this widespread stigma and discrimination and violence, people who inject drugs are beset by persistently high rates of HIV. Viral hepatitis and tuberculosis rates among people who use drugs also are high in many parts of the world. These preventable and treatable diseases, combined with overdose deaths that are equally preventable, are claiming hundreds of thousands of lives each year.
This is a problem that has a clear solution: harm reduction. Study after study has demonstrated that comprehensive harm reduction services—including needle–syringe programmes, drug dependence treatment, overdose prevention with naloxone, condoms, and testing and treatment for HIV, tuberculosis, and hepatitis B and C—reduce the incidence of blood-borne infections, problem drug use, overdose deaths and other harms. Countries
that have successfully scaled up harm reduction have experienced steep declines in HIV infections among people who inject drugs. In Ireland, for example, new HIV diagnoses among people who inject drugs have decreased by 70% since methadone maintenance therapy was introduced (Figure 3.10).
However, change within many countries has been slow.
Needle–syringe distribution and opioid substitution therapy coverage remain low in most of the 54 countries that have reported data for both indicators to UNAIDS in recent years. Just three high-income countries—
Austria, Luxembourg and Norway—reported that they had achieved United Nations-recommended levels of coverage for these programmes (Figure 3.9). Those three countries are home to less than 1% of the global population of people who inject drugs.
A special UNAIDS report, Health, rights and drugs: harm reduction, decriminalization and zero discrimination for people who inject drugs, was published in March 2019, ahead of the Ministerial Segment of the 62nd Session of the Commission on Narcotic Drugs. The report reviews in detail the availability, gaps, enablers and barriers to comprehensive harm reduction services.
HIV DA TA
A COMBINATION APPROACH TO HIV PREVENTION
Consistent condom use is achievable Condoms are a cheap and highly effective means of preventing HIV, STIs and unwanted pregnancies.
Condom use appears to have increased in most of sub-Saharan Africa over the last decade. Among the 17 countries in the region with at least two Demographic and Health Surveys conducted since 2008, 13 countries showed increases in reported condom use among young women (aged 15–24 years) at last higher risk sex with a nonmarital, noncohabiting partner, while there were decreases in Benin, Ethiopia, Ghana and Madagascar.
However, despite their many advantages, median condom use by men at last higher risk sex in 27 sub-Saharan African countries with recent data was only 58.6%, far from the global target of 90% by 2020. Specific districts or municipalities in 11 of these countries have achieved 80% condom use by men at last higher risk sex (Figure 3.11). In approximately half
of the 27 countries, condom use was highest in the capital city. Countries with already high condom use can optimize programmes by learning from their high-performing cities and other locations. Countries with medium condom use show considerable variation in use, suggesting high potential for internal and cross-country learning, while countries with low condom use could primarily learn from countries with high use.
Sex workers often report condom use with their last client. However, many struggle to negotiate condom use with all of their clients. In some countries, condoms are also still used by law enforcement officers as evidence of sex work, discouraging sex workers from keeping enough supplies with them. Data from 29 countries show that there is a large difference between reports of condom use at last sex among sex workers and consistent use of condoms. Twenty-one countries reported 80% or higher condom use at last sex, but just four reported consistent condom use of 80% or higher (Figure 3.12).
PART 1
|
PART TITLE0 10 20 30 40 50 60 70 80 90 100
Per cent
National Lowest subnational Highest subnational
Harare Chitungwiza Oshana Zomba City Maseru Nyanza Haut-Ogooué North-West Dakar Brikama Kigali Acholi Lomé Ngazidja Kogi Lusaka Harari Zaire Bujumbura Mairie Conakry Maputo City Monrovia N'Djaména Bamako Upper West Littoral (Cotonou) Kinshasa Western Urban
Global target (90%)
High Medium Low
FIGURE 3.11 Condom use among men (aged 15–49 years) at last high risk sex with a nonmarital, noncohabiting partner, national and subnational, countries with available data, 2012–2018
National Lowest subnational Highest subnational Source: Population-based surveys, 2012–2018.
49
HIV DA TA
5
0 10 20 30 40 50 60 70 80 90 100
Mexico Cambodia Iran (Islamic Republic of) Zambia Rwanda Ukraine Pakistan China Burkina Faso Malawi Nigeria Mongolia Montenegro Bangladesh Eswatini Viet Nam Benin Botswana Myanmar Kenya Uganda Guyana Zimbabwe India Sri Lanka Lao People's Democratic Republic Peru Jamaica Eritrea
Percent
Consistent condom use in the last reported period Condom use at last sex Consistent condom use in the last reported period
Condom use at last sex
FIGURE 3.12 Condom use among sex workers, selected countries, 2014–2018
Source: Literature review by UNAIDS and the Key Populations Program of the Center for Public Health and Human Rights, Johns Hopkins University. See references at the end of the chapter for details.
A Convictus mobile unit provides a range of services to sex workers at hotels, saunas, truck stops, brothels and apartments.
Credit: Convictus