Only about half of countries studied offer some level of opioid substitution therapy or needle exchange.
Sarah Larney, PhD
Given poor levels of current coverage, scaling up HIV and Hepatitis C (HCV) interventions for people who inject drugs remains a crucial priority for preventing global epidemics, according to a new study.
The report published in The Lancet Global Health found that in 2017, syringe and needle exchange programs were available in just 93 of 179 countries with evidence of injecting drug use. Moreover, opioid substitution therapy had only been implemented in 86 countries.
Coverage varies widely between countries, but is frequently low when measured against World Health Organization indicators. For example, study authors found that less than 1% of people who inject drugs live in countries with high coverage of both needle and syringe programs and opioid substitution therapy.
The United Nations’ Sustainable Development Goals for Good Health and Well-being, set in 2015, prioiritize combating hepatitis and ending the epidemic of AIDS by 2030.
“Those things won't happen unless we properly prevent and treat infectious diseases in people who inject drugs,” said Sarah Larney, PhD, lead author of the study, senior research fellow, National Drug and Alcohol Research Centre (NDARC). “Coverage is still very low by any standard if you wanted to actually prevent any kind of infectious diseases.”
In the US, provision of services is in the lower to upper-lower range, according to Larney, and the recent opioid epidemic has shown a need for “extremely expanded” access to opioid substitution therapy. Access to needle and syringe programs still varies widely within the US, Larney added.
In some cases, positive trends of access to interventions in the US has reversed.
“In Indiana for example, needle and syringe programs were introduced in response to the HIV outbreak,” Larney noted. “That’s actually now been rolled back after people perceived that the outbreak is under control. And that’s extremely unfortunate because it’s only a matter of time until these types of outbreaks flare up again.”
While coverage of interventions worldwide remains low, another Lancet Global Health report found that overall prevalence of injecting drug use remains widespread, estimating that there are 15.6 million people who inject drugs between the ages of 15 and 64 worldwide.
A multilingual team of researchers from academic institutions in Australia, the UK, Portugal and Ukraine reviewed 55,671 papers and reports, and extracted data from 1,147 eligible records. Since the most recent review in 2008, they found an increase of 31 countries with a prevalence of injecting drug use, mostly in sub-Saharan Africa and the Pacific islands.
This revealed a global trend, according to Larney, who was also joint senior author of the second study: “Injecting is going down in more developed regions and increasing in less developed regions.”
Of 15.6 million people who inject drugs, the study estimated that 17.8% are living with HIV, 52.3% are HCV-antibody positive, and 9.1% are HBV surface antigen positive, although the report noted that there is substantial geographic variation in these levels.
Global trends may be partly due to the cyclical nature of drug use, authors suggested.
“Different drugs become popular: sometimes the drugs that are popular are injected, sometimes they're not injected and it varies between countries and even within the same region,” Larney said. “Eastern Europe, for example, is having issues with injecting of new psychoactive substances — synthetic drugs that are designed to mimic existing psychoactive drugs. And those are often injected multiple times a day and can cause quite a lot of harm. Whereas in other places, it's people doing old-fashioned heroin.”
Authors identified the socio-demographic characteristics of intravenous drug users and estimated that 27.9% of people who inject drugs globally are younger than 25 years old.
“When you're talking about young people, you're talking about people who are potentially being taken out of the workforce early. They're forming behaviors that can become persistent at quite a young age and will need quite a lot of intensive care throughout their lives in terms of medications and treatments for HIV and Hep C,” Larney said.
Older drug users have a host of other health complications.
“In Australia and Western Europe, people who inject drugs are actually an aging cohort,” Larney said, namely people who have lived with infectious diseases like HCV for a long time. “They’re now starting to develop cirrhosis, liver cancer, end stage liver disease, very high rates of cardiovascular disease and other cancers associated with that population, so it's really a very diverse picture with quite a lot of health harm related to injecting.”
The study estimated that 21.7% of people who inject drugs had experienced homelessness or unstable housing within the past year, and 57.9% had a history of incarceration.
“People who inject drugs tend to be highly marginalized, highly stigmatized and so there's a whole range of things that come with that,” Larney said. “They're often exposed to violence in their social milieux, more likely to be arrested, and being incarcerated becomes a high-risk period for using and injecting and getting infectious diseases.”
Women who inject drugs are more likely to be exposed to a violent sexual nature, further increasing the risk of exposure to infectious diseases, she added.
In studying the gender composition of intravenous drug users, the analysis revealed trends that could be attributed to cultural values, according to Larney. In South Asia, for instance, the proportion of intravenous drug users appeared to be 95% male.
“But that becomes complicated,” Larney said. “Is that just because we simply aren’t identifying women who inject drugs in those environments, given the extreme stigma associated with women injecting drugs?”
Such reporting issues suggest a need to be mindful of uncertainty in the data, and it’s important to acknowledge there's no way to have a true number.
Larney hopes that the studies will provide data that can be used to make a difference on the ground, and that health organizations can use them to advocate for people who inject drugs, for more expensive programming, targeting resources to where they’re most needed, expanding access to care, and advocationg for implementation where services are only partly used.
“We've identified that access to services has been shrinking since the withdrawal of international donors, so we’re trying to highlight those countries and saying that we need to make sure that more money is going into those services,” Larney said. “Because without funds, things will just get worse, they certainly won't get better.”