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Keywords:

  • Access to care;
  • antiretroviral therapy;
  • HIV;
  • injecting drug users;
  • opioid substitution treatment

Uhlmann et al.[1] studied methadone prescription in HIV-infected drug users using an elegant longitudinal design with appropriate adjustment for potential correlates and confounders to estimate any benefits on initiation and adherence to antiretroviral therapy (ART).

Increased initiation of ART as demonstrated by Uhlmann et al. supports findings from previous research, including a study with a similar longitudinal design [2] and a Swiss cohort study [3]. A previous retrospective study showed that injecting drug users (IDUs) receiving ART were more likely to have had access to methadone in primary care and weekly take-outs of methadone [4].

Previous studies have also reported positive effects of methadone on ART adherence. This applied whether methadone was taken under direct supervision or provided [5] as a take-home medication [3,6]. The effect was especially notable in individuals who had abstained from drug injection for some time [3,7].

As longer duration of opioid substitution treatment (OST) is associated with reduced heroin injecting and associated linearly with undetectable viral load in HIV-infected IDUs [7], methadone doses of at least 80 mg/day are required to increase retention and optimize HIV prevention. Significant drug–drug interactions can occur between methadone, ART and some antituberculosis drugs. Therefore, access to buprenorphine as another option for opioid dependence treatment is very helpful.

While the combination of needle syringe programmes and OST reduces HIV seroconversions substantially [8] among IDUs by reducing heroin use [9] and needle sharing [10,11], measures to reduce HIV sexual risk behaviour and sexual transmission among and from IDUs have been unsuccessful. Nevertheless, achieving high levels of adherence and a low viral load with ART reduces both parenteral and sexual transmission of HIV among and from this population [12,13]. This is particularly important in the many parts of the world where populations of IDUs are predominantly male and overlap considerably with female commercial sex workers.

HIV in IDUs is often associated with considerable co-infection with tuberculosis and hepatitis B and C. This complicates the provision of ART and increases mortality substantially. Stabilizing co-infected patients with OST facilitates treatment of tuberculosis and hepatitis and reduces the risk of the emergence of multi-resistant tuberculosis. Increasingly, the challenge will be to integrate treatments for drug problems and HIV with provision of HIV prevention and treatment for tuberculosis, hepatitis, sexually transmitted infections and mental health problems while also encouraging social integration. This integrated treatment is required in both community and prison settings.

Although the provision of OST and ART began in relatively well-resourced developed countries, most of the future growth will occur in resource-poor settings. Although providing these services will no doubt be costly, not providing them will be even more expensive. Mathematical modelling suggests that universal voluntary HIV screening followed promptly by ART uptake virtually eliminates new HIV infections in less than 5 years. The costs of this approach in the long term could reduce to very low amounts as progress towards elimination is achieved [14].

Despite the unequivocal demonstration of substantial benefits of methadone for ART-treated opioid-dependent individuals and consequent public health benefits, access to methadone in most countries is poor. Paradoxically, this is particularly common in countries with very high HIV prevalence among IDUs—such as eastern European and Asian countries.

The major obstacle to achieving HIV control among IDUs today is the continuing ideological rejection of prevention measures shown unquestionably to be effective, safe and cost-effective. Where harm reduction has been accepted, expansion is often far too slow. The net result is that acceptable coverage rates might only be achieved in many parts of the world in another 20 years. This would be some 40 years after the epidemic began in this population. Many countries are still reluctant to allow any prescribing of methadone or similar drugs, fuelling the demand for opioids from the black market and increasing the number of overdose deaths and HIV infections. The denial of more than 40 years' research documenting the important benefits of methadone is most pronounced in the former Soviet Union countries, where HIV among drug users is endemic and the prevailing ‘narcology’ approach relies on diverse evidence-free interventions, including imprisonment, torture, electroshock or lobotomy [15].

The study by Uhlmann et al. reminds us of how far the gap still is between evidence and international policy and practice in HIV prevention and care of drug users.

References

  1. Top of page
  2. Declaration of interests
  3. References
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