Taking stock of an off-track AIDS response: During 2011-2012, Uganda attracted concern—and criticism—as a result of its troubling epidemiological trends, indicating an off-track response to HIV. The Uganda AIDS Indicator Survey showed that prevalence had risen from 6.4 to 7.3% between 2006 and 2012 and incidence also rose during the same period. Condom use by men and women declined starkly over the same period—reported condom use during sex with a non-cohabitating partner declined significantly between 2005 and 2011 from 47% to 29% and from 53% to 38% among women and men, respectively. Importantly, Uganda was the only PEPFAR “Focus Country” reporting rising HIV incidence—all other PEPFAR focus countries have consistently reported declines in incidence as well as prevalence in recent years.

At the same time, recent game-changing scientific advances in HIV prevention and clinical care are making it possible for all high-burden countries to begin to achieve an “AIDS Free Generation,” defined as a halt to sexual transmission, an end to disease progression for those who are HIV positive, and an end to perinatal transmission. In particular, recent data show that HIV treatment is not only life saving but is also one of the most powerful prevention tools available—groundbreaking new research shows that earlier treatment of HIV positive people—at CD4>350—results in 96% reduction in the risk of HIV transmission through sex with an uninfected partner,4 is highly cost effective, and provides significant clinical benefit.6 Uganda’s faltering response means an attaining an AIDS Free Generation will take stronger, more urgent action—with bolder leadership.

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Ending AIDS in Uganda: What will it take?

People who inject image and performance enhancing drugs, such as anabolic steroids and melanotan, are at greater risk of HIV, hepatitis B and hepatitis C infection than previously thought. In England and Wales, the level of HIV infection among this group is similar to that among people who inject psychoactive drugs, such as, heroin and crack-cocaine. The proportion that had ever been infected with hepatitis B is lower than that among people who inject psychoactive drugs, although recent survey findings suggest the level of infection has increased over time.

Infections remain common among people who inject psychoactive drugs. Overall around half of this group have been infected with hepatitis C; around one in every 100 has HIV; and almost one-third report having a recent symptom of an injecting site bacterial infection. Hepatitis B infection among people who inject psychoactive drugs has declined, probably reflecting the marked increase in the uptake of the hepatitis B vaccine.

Needle and syringe sharing is lower than a decade ago, although around one in seven of people who inject psychoactive drugs continue to share needles and syringes. There has been a recent increase in the injection of amphetamines and amphetamine-type drugs, such as, mephedrone. Though these psychoactive drugs are much less commonly injected than opiates, crack-cocaine, or image and performance enhancing drugs, there is evidence that their injection is associated with higher levels of infection risk. Keep up-to-date with drug policy developments by subscribing to the IDPC Monthly Alert.

Keep up-to-date with drug policy developments by subscribing to the IDPC Monthly Alert.

Shooting up: Infections among people who inject drugs in the UK in 2012

In the first decade of the 21st century the United States began to experience a shift in the 30-year buildup to a world record prison system. Although the decade ended with an increased number of people in prison, the rate of growth overall was considerably below that of previous decades and since 2008 the overall number of people in state prisons has declined slightly each year.

Scholars are beginning to analyze the relative contributions of changes in crime rates, criminal justice policies, economics, and demographics to the slowing growth rate of the prison system, but one area that has gone largely unexplored is the impact of such changes on racial disparities in imprisonment. As is well known, black/white
disparities in the use of incarceration have been profound for quite some time. Since the 1980s a series of analyses have documented these trends at the national level as well as examining variation in disparity among the states.

The changing racial dynamics of women's incarceration

More than two billion people in middle-income countries (MICs) lack access to essential medicines. Medicines are expensive, and consume 25 to 65 percent of the total private and public spending on health, and 60 to 90 percent of household expenditure in MICs. In the public sector, there is poor availability of medicines and patients are forced to purchase medicines from the private market. The Global Burden of Diseases 2010 study shows that MICs rather than experiencing a classic ‘epidemiological transition’ in which infectious diseases dissipate and non-communicable diseases (NCD) emerge, are facing a ‘dual burden’ in which infectious diseases are still prevalent, especially HIV, viral hepatitis and tuberculosis, while NCD rates are rising. Access to affordable medicines is therefore of central importance in ensuring universal access to health care in these countries.

Middle-income countries (MICs) are facing a crisis of containing costs for treating people living with HIV. These countries carry a high burden of HIV, and transmission of the virus is often concentrated amongst key populations: people who inject drug (PWID), men who have sex with men (MSM), sex workers (SW), transgender (TG), prisoners and migrants. The highest numbers and the highest prevalence of PWID with HIV are in East and Southeast Asia (17 percent), Eastern Europe (27 percent), and Latin America (29 percent). HIV prevalence is on average 13 times higher among MSM compared to the general population. In most parts of the world, sex workers experience higher prevalence of HIV than the general population. Access to treatment can be a challenge for key populations given the structural barriers such as laws and legislation that criminalize their behavior, stigma and discrimination, and lack of general acceptance in society. But even when such barriers are overcome, medicines including ARVs may not be available (‘stocked out’), largely because of the high costs as well as poor procurement and distribution system. The high cost of medicines are often the reasons governments claimed to have prevented them from including or limiting access to treatment as part of the public health insurance or social security system. Moreover, a country’s ability to pay is not always commensurate to
willingness to pay especially when it involves key populations.

Access challenges for HIV treatment among people living with HIV and key populations in middle-income countries

This report is the second publication in a series where we examine funding shortages for TB and HIV programmes in Eastern Europe and Central Asia (EECA).The first publication, “Bridging the Gap: Whythe European Union must address the Global Fund’s funding crisis to tackle the escalating HIV and TB epidemics in Eastern Europe and Central Asia” explored the cancellation of the Global Fund to Fight AIDS, Tuberculosis and Malaria’s eleventh funding window in 2011 and how this left some countries without the financial support needed to aggressively combat their disease epidemics. This report builds on our previous publication by analysing three cases studies to demonstrate the continued impact of TB and HIV in the region and to show the effects of international donor aid diminishing in middle-income countries. The current situation for TB and HIV programmes in the region remains serious. These diseases urgently require sustained political and financial support from both domestic and international sources, including regional level aid from the European Union.

The Global Fund to Fight AIDS, TB and Malaria, historically the largest international donor for TB and HIV programmes in the EECA region, has adopted a New Funding Model (NFM) that will significantly reduce the amount of support available for middle-income countries. This includes support to civil society organisations that deliver TB and HIV services and are essential to creating environments where national governments are held accountable for properly addressing the health needs of their citizens. A Global Fund modelling of funding allocations under the NFM indicated that just three percent of total resources would be allocated to EECA. This represents a 50 percent decrease compared with what was previously available.

Bridging the gap: How the EU can address the funding crisis for TB and HIV programmes in Eastern Europe Central Asia

Injection drug users who take measures to reduce the risk of contracting hepatitis C are not always motivated by messages about preventing transmission of the disease, according to research published in 

Instead, health services should use messages appealing to pragmatic concerns, such as vein care, preventing painful injections, and avoiding risk of withdrawal.

Researchers from the London School of Hygiene & Tropical Medicine’s Staying Safe project interviewed 37 long-term injection drug users in London to discover those practices which may prevent exposure to hepatitis C and other blood-borne pathogens.

Approximately 216,000 people in the UK are living with hepatitis C. It is estimated that up to nine out of 10 cases in England are caused by injecting illegal drugs, and that nearly half of people who inject drugs in England may be living with the virus.

All participants engaged in protective practices irrespective of serostatus. It is important to consider the relative importance of different motivations framing protective practices in order to formulate harm reduction interventions which appeal to the situated concerns of PWID, especially given that these protective practices may also help protect against HIV and other blood borne infections.

- See more at: http://blogs.lshtm.ac.uk/news/2013/10/31/reducing-the-risk-of-hepatitis-c-among-people-who-inject-drugs/#sthash.h1DhTr6r.dpuf

Hepatitis C avoidance in injection drug users: A typology of possible protective practices

The epidemiological reality of HIV infection in Egypt favours prioritizing efforts to the high risk groups rather than the general population. Hence, harm reduction should be at the core of interventions targeting HIV.

The current study revealed that there is still a long way to go to enhance the role of these interventions in influencing a significant behaviour change among target group.

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Harm reduction in Egypt: The insight of injecting drug users

A report published at the end of the third year of the study showed four distinct findings in relation to higher likelihood of drug use and binge drinking, higher likelihood of substance dependency and barriers to help-seeking in relation to substance use among LGB people.

This report further explores problematic and dependent drug and alcohol use and help seeking behaviour, particularly among those who indicated substance dependency.

This is the penultimate year of the POTP study, and in 2014 we plan to publish comprehensive recommendations for commissioners and policy makers, drug and alcohol service providers, the LGB&T voluntary and community sector, and LGB communities themselves.

At present, we recommend implementation of the actions outlined in the Action Plan that was developed with key stakeholders in the substance use field following the launch of the 2009-11 report.

An accompanying report presents case studies based on the lived experiences of three LGB people with a history of substance use and/or current substance use. These three cases offer a useful contrast to the survey data, providing important biographical detail about the life processes and issues that inform decisions and actions around substance use.

Part of the picture: Lesbian, gay and bisexual people's alcohol and drug use in England

Injectable opioid treatments are more cost-effective than optimised oral methadone for chronic refractory heroin addiction. The choice between supervised injectable heroin and injectable methadone is less clear. There is currently evidence to suggest superior effectiveness of injectable heroin but at a cost that policy makers may find unacceptable. Future research should consider the use of decision analytic techniques to model expected costs and benefits of the treatments over the longer term.

Click here to read the full publication (restricted access)

Cost-effectiveness of injectable opioid treatment versus oral methadone for chronic heroin addiction

Cannabis dependence is a disorder primarily experienced by young adults, especially in higher income countries. It has not been shown to increase mortality as opioid and other forms of illicit drug dependence do. Our estimates suggest that cannabis use as a risk factor for schizophrenia is not a major contributor to population-level disease burden.

The global epidemiology and contribution of cannabis use and dependence to the global burden of disease

In the last few years, the debate on illicit drugs – long dominated by voices that favor repressive and punitive policies framed by prohibitionist strategies – has broadened and gained new momentum. This publication summarises the different drug law reform movements in the Latin American region.

From repression to regulation:  Proposals for drug policy reform

Responses to problematic drug use continue to improve in Scotland. Service provision is more coherent, waiting times are down and there is a clearer understanding that all steps in the recovery journey need to be supported.

Commissioners and services are focusing on raising standards at a time when resources are at a premium. SDF’s Big Lottery-funded National Quality Development Programme has helped in excess of 80 projects to implement changes aimed at improving recovery outcomes – often identifying ways to make better use of existing resources.

This is an evolving process. Needs identified by managers and frontline workers have led to the development of SDF’s well-received Sexual and Reproductive Health Initiative and intensified our focus on New Psychoactive Substances through training, events and collaborative working at local and strategic level.

We hope to attract further funding for our Quality Development initiative to help services implement the recommendations in the Opiate Replacement Therapies Review and the new Quality Improvement Framework, both of which underline the need for the wider psycho-social supports.

Publications