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Harm reduction prevents HIV, national evidence from Ukraine and Greece shows
Mara Kardas-Nelson, 2014-07-30 11:10:00

Two presentations given at the 20th International AIDS Conference, held in Melbourne, Australia July 20-25, 2014, provide significant evidence that harm reduction programmes successfully prevent HIV infection among people who inject drugs (PWID). Other barriers remain, however, to keep these programmes in place in the long term, and to ensure that sexual as well as injecting behaviours are positively affected so as to further decrease HIV incidence and prevalence both among PWID, and the population as a whole.

Speaking on a July 24 panel entitled "People Who Inject Drugs: Risks and Responses," Olga Varetska of the International HIV/AIDS Alliance Ukraine presented data showing that HIV prevalence and incidence has dropped significantly among the country's drug using population alongside a national harm reduction programme that, among other interventions, offers clean syringes, condoms, and HIV testing ("How do PWID prevention activities impact the HIV epidemic? Case of Ukraine"). There are approximately 310,000 PWID in Ukraine, with a mean HIV prevalence of 18%.

Looking at nearly 10 years of data, Varetska notes that HIV incidence among PWID decreased from 2010, with an especially substantial decrease among young PWID, from 1,038 new cases in 2005 to only 225 in 2012. A drop in prevalence within the PWID is even more dramatic, from approximately 12% in 2007 to just under 5% in 2013 (again, the drop in young PWID is more pronounced, from 20% in 2007 to just under 5% in 2013). Varetska says the drop is due to a reduction in risky behaviours, particularly needle and syringe sharing (although the use a preloaded syringe and container sharing remain high). Through the national harm reduction programme, each PWID gets 100 clean syringes annually.

Despite all this good news, Ukraine’s overall HIV incidence rate has been on the rise since 2001. Heterosexual transmission is the primary culprit: while incidence has been decreasing in high-risk populations like female sex workers and men who have sex with men (in addition to PWID), half of all new cases in 2013 were attributed to heterosexual transmission. Young women are the most likely to be newly infected.

What does this have to do with drug users? Varetska points out that sexual behaviour among PWID continues to be poor: 50% of PWID do not use condoms and the population generally practices risky sexual behaviour (the majority of PWID being served by the national harm reduction programme--nearly 80%--are men). Based on this, and using a triangulation study, Varetska hypothesizes that it is sexual transmission between PWID and their partners that is, at least in part, driving the country's epidemic. Given this, she says it's imperative that in addition to continuing the country's harm reduction efforts (which are at risk of significant funding cuts), the sexual practices of PWIDs and their sexual partners be targeted in order to address the epidemic at large.

Results of Greece's famed ARISTOTLE programme, presented by Vana Sypsa from the National Retrovirus Reference Center at the University of Athens’s Medical School, also show that harm reduction programmes work--and quickly and extremely effectively ("Trends in HIV-1 incidence during an outbreak among injecting drug users in Athens, Greece: results of a serobehavioural survey (ARISTOTLE programme)").

ARISTOTLE ran from August 2012-December 2013, in response to what Sypsa calls an "outbreak" of HIV among PWID: in 2011, countrywide 266 HIV cases in PWID were diagnosed, 16 times higher than in 2010. ARISTOTLE offered HIV screening, and a prevention, treatment and care package, for PWID living in Athens who had injected drugs in the last 12 months and who were 18 years old, in an attempt to decrease HIV incidence among this population. (In order to determine when a PWID became infected with the virus, in addition to providing HIV testing, ARISTOTLE used a  Limiting Antigen Avidity Assay to identify recent infections.) Throughout the programme, 3,320 people participated over five "rounds.”.

Comparing incidence from round to round, Sypsa notes that there was at least a 78% decrease in incidence from the start to the end of the programme. Using a model, researchers suggest that incidence was 88% lower with ARISTOTLE than if the programme had not been implemented.

But Sypsa notes that other interventions to stymie the outbreak were being done simultaneously to ARISTOTLE, notably an increase in access to opioid substitution therapy and needle exchange programmes. Using self-reported data from ARISTOTLE participants, Sypsa says that while the percent of PWID who said there were receiving OST throughout the five rounds increased significantly over time, it was still "suboptimal" and couldn't alone explain the dramatic decrease. As for needle exchange programmes, the number of participants who self-reported receiving syringes actually decreased overtime.

In concluding that ARISTOTLE was the most likely reason why incidence dropped as significantly and quickly as it did, Sypsa notes that, based on data from behavioural questionnaires and potentially as a result of a comprehensive package offered through the programme--such as referral to ART, peer support, monetary incentives to join the programme and to come back for the results of an HIV test, and access to psycho-social services--participating PWIDs reported safer injecting practices, and safer sexual practices among those who were HIV positive. There was also a significant increase in participants knowledge of their status, with only 20% of those HIV positive knowing their status in the first round, compared to nearly 90% in the fifth round.

Given the success of the programme, Sypsa said that there are efforts to start the programme again, and to create, and continue, programmes like it around the globe.

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