Situation: People who inject drugs (PWID) are 24 times more likely to be infected with HIV than the rest of the population. Therefore, HIV and AIDS prevention policy among this group should be different. However, the question remains—how effective is it?
In reality: It is very difficult to understand what is actually happening with HIV/AIDS prevention policies among drug users in different countries. The reason for this is the lack of reliable tools for measuring the effectiveness of preventive measures.
Peter Meylakhs, from HSE University - St. Petersburg, together with colleagues from Georgia State University (USA) and Tarbiat Modares University (Tehran), have developed the HIV-PWID Policy Index (HPPI)—an international policy index for HIV prevention among people who inject drugs. This is the first major tool for assessing and comparing the extent to which HIV/AIDS prevention policies among PWID have been developed in 105 countries. The top performing countries were Spain, Switzerland, Luxembourg, Moldova, and Kyrgyzstan. The poorest performing included Nicaragua, Japan, and Syria. Russia ranked 59th. An article describing the methodology and assessment processes of the new index was published in the International Journal of Drug Policy. The work of the HSE researcher has been supported by the Russian Academic Excellence Project 5-100.
There are more than 15.5 million people worldwide who inject illicit drugs each year. About one in six of these individuals is HIV-positive. The total number of newly diagnosed HIV cases among PWID continues to increase. Nonetheless, the number of infected people in this group varies from country to country, with certain countries having higher infection rates than others. This is because of the differing specifics of HIV/AIDS prevention policies.
The researchers note that national educational, preventive, therapeutic and legal responses to address the problem of injected drug use can have a strong influence on different risk factors for HIV among drug users. Interventions such as opioid substitution treatment, needle exchange and antiretroviral therapy can substantially reduce the spread of HIV among PWID.
However, at the moment, only about half these countries are implementing evidence-based policies in this area. Many others continue to subject their drug-dependent population to punitive criminal and other counterproductive measures.
Previously, the academic community had made only one attempt to construct an HIV prevention index for drug users (Lucy Platt and her colleagues at the London School of Hygiene and Tropical Medicine). However, as recognised by the authors themselves, the index is still in its ‘raw’ stage. It is based on a small number of indicators for 50 European countries.
With this in mind, Peter Meylakhs set about the task of developing a more precise tool. The index was originally constructed based on data from the WHO European region (Europe and the CIS). Then, in collaboration with international colleagues, he extended the geographical scope of the index to countries on all continents.
The development of the new index was done in several stages. Initially, a conceptual framework was drawn up to determine the domains and policies for constructing HPPIs. A total of six conceptual domains were included in the index, showing the status of HIV prevention among PWID in the following areas:
1. Needle and Syringe Programmes (NSPs), including those implemented in jails.
2. Methadone Replacement Therapy (Opioid Substitution Treatment). Treatment of drug dependence by prescribing methadone (a synthetic opioid). It has proven its effectiveness and is offered in all countries of America, Western Europe, and many countries of Eastern Europe. This treatment is not used in Russia—methadone is on the list of banned drugs.
3. Testing and Treatment. These include national preventive strategies for HIV testing, counselling for PWID and also access to antiretroviral treatments.
4. Information and Education. Various national measures aimed at improving the health and reducing risky behaviours among PWID.
5. Monitoring and Evaluation. National monitoring and evaluation efforts.
6. Legal and Political Climate. Legal and policy aspects to HIV prevention among PWID, including non-discrimination laws and decriminalization of HIV/PWID status.
After that, the authors analysed the quality and availability of the indicators for these areas at the individual country level. They initially collected data for 181 countries. A total of 76 countries were excluded from the analysis due to missing data on specific policy index indicators. In their collection of data, the researchers examined data sources from international organizations such as the Joint United Nations Programme on HIV/AIDS (UNAIDS), the United Nations Office on Drugs and Crime (UNODC), the WHO and the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA).
At the third stage, the authors employed FMLDEA (fuzzy multi-layer data envelopment analysis)—a multilayer data analysis to aggregate the indicators into a composite index. The figures may vary from 0 to 1. The larger the number, the higher the level of HIV prevention among injecting drug users in a given country.
The results confirmed that there are substantial national and regional variations in HIV prevention policies among PWID. However, they do not necessarily depend on a country’s level of economic development. Among the Top-10 countries, along with Switzerland, Norway, France and Canada, were post-Soviet countries—Kyrgyzstan, Armenia, and Moldova. Japan ranked second to last, between Cape Verde (Africa) and Nicaragua.
The high performance of some post-Soviet states could be attributable to efforts to provide international aid following the collapse of the USSR and the introduction of scientifically proven methods of prevention. ‘For example, Kyrgyzstan ranks fifth in the HPPI rating because the government promotes evidence-based measures aimed at preventing and treating HIV among PWID, including official support for needle exchange programmes,’ the authors note. However, they also stress that a recent study has documented significant barriers to accessing NSP services in Kyrgyzstan.
The low effectiveness of HIV prevention policies among PWID in some countries may be explained, in part, owing to the relatively low number of injecting drug users in those countries. Therefore, HIV may not be perceived as a problem by the state. For example, in the Middle East and North Africa, the proportion of PWID among the population aged 15-64 is 0.12%, while in Eastern Europe it is 1.30%.
Overall, North America (0.82) and Europe (0.81) have the most effective HIV prevention policies for PWID. The most ineffective policies are in South America (0.59), Africa (0.50) and especially Central America (0.22). Oceania (0.76) and Asia (0.66) are in the mid-range. As the authors point out, however, these averages mask significant sub-regional differences. For example, Central Asian countries perform significantly better (0.85) than the Middle East (0.33).
According to the index data, Russia ranks 59th with a score of 0.745. This is an indication that the country needs to pay more attention to HIV prevention among PWID in the country. According to official statistics from the Federal Centre for AIDS Prevention and Control, among all HIV-infected Russians with a known cause of infection identified between 1987 and 2020, almost 60% were infected through drug use. By the end of the first half of 2020, there were 1,094,050 Russians with a laboratory diagnosis of HIV infection.
Among the main reasons that Russia has not been at the forefront of HIV prevention policies among PWID, Peter Meylakhs believes, is the ban on substitution therapy and the insufficient implementation of programmes to reduce needle sharing.
HIV prevention among injecting drug users has received considerable international attention. For example, UNAIDS has set a target of 90% access to HIV prevention services for PWID, including HIV testing, antiretroviral therapy, needle and syringe programmes, clinical services, etc. However, monitoring the implementation of such programmes at the national level is difficult owing to the lack of reliable tools for its implementation.
This is why the HIV-PWID Policy Index was developed. ‘It can be used for analytics and to enhance understanding, as well as informing politicians, professionals and the public what is happening in the area of HIV prevention for PWID in different countries, in the same way that other indices, such as Transparency International, are used,’ says Peter Meylakhs.
He also suggests that the index can also be useful in the development of social programmes—the introduction of evidence-based and proven interventions that can reduce the prevalence of HIV among PWID, such as substitution therapy and needle distribution.
Prevalent cases are all cases of a certain disease at a specific moment in a given population.
At the same time, he also notes that, as a monitoring tool, HPPI has a number of limitations. It is only as reliable as the basic data used to construct it. Moreover, countries from certain regions of the world, including most of sub-Saharan Africa and South America, have limited data on HIV/AIDS, which can also affect the accuracy of the statistical measurements.
Eric L. Sevigny, University of Georgia (USA)
Peter Meylakhs, Senior Research Fellow, International Centre for Health Economics, Management, and Policy, HSE Campus in St. Petersburg
Mohammad Yavad Feizollahi, University of Georgia (USA)
Mohamed Reza Amini, Tarbiat Modares University, Tehran (Iran)