- Email: [email protected]
Curbing HIV incidence in people who inject drugs
Comment
9
10
Newell ML, Coovadia H, Cortina-Borja M, Rollins N, Gaillard P, Dabis F. Mortality of infected and uninfected infants born to HIV-infected mothers in Africa: a pooled analysis. Lancet 2004; 364: 1236–43. Violari A, Cotton MF, Gibb DM, et al. Early antiretroviral therapy and mortality among HIV-infected infants. N Engl J Med 2008; 359: 2233–44.
11 12
Rosen S, Fox MP. Retention in HIV care between testing and treatment in sub-Saharan Africa: a systematic review. PLoS Med 2011; 8: e1001056. Mugglin C, Estill J, Wandeler G, et al. Loss to programme between HIV diagnosis and initiation of antiretroviral therapy in sub-Saharan Africa: systematic review and meta-analysis. Trop Med Int Health 2012; 17: 1509–20.
Curbing HIV incidence in people who inject drugs In June, 2016, the UN General Assembly adopted a Political Declaration On Hiv And Aids: On The FastTrack To Accelerate The Fight Against HIV And To End The AIDS Epidemic By 2030. The document noted the absence of global progress made in reducing transmission of HIV among people who use drugs, particularly those who inject drugs (PWID).1 UNAIDS estimates that between 2010 and 2015, the number of new adult HIV infections decreased or remained static in every region except eastern Europe and central Asia, where there was a 57% increase, with PWID accounting for 51% of new infections.2 Ukraine remains one of the countries hardest hit by the HIV epidemic in Europe with an estimated 238 000 people living with HIV.3 20 years after the outbreak of HIV among PWID, this route of infection remains the main force pushing the epidemic forward. In 2011, at the time of the study by Robert Booth and colleagues4 published in The Lancet HIV, an estimated 310 000 PWID lived in the country with an overall HIV prevalence of 19·7% (compared with 0·62% prevalence in the general adult population).5 The demographics of drug users, drug-use patterns, and social issues surrounding drug use in Ukraine differ when compared with other countries and regions in the world battling the problem of illicit substance use and its consequences. Most injected drugs are homemade from various ingredients and precursors, often extracted from legally available over-the-counter medicines (eg, codeine or pseudoephedrine from cold medicines), solvents, and so on. A particularly harmful form of such drug mixing is so-called krokodil,6 which is used intravenously causing health damage. Drug scenes vary depending on the availability and access to these drug precursors and ingredients in different provinces of the country.7 Needle exchange and other harm reduction services along with opioid substitution treatment are core elements of WHO guidelines to prevent spread of HIV among PWID.8 Reduction of HIV incidence among PWID requires measures to address structural www.thelancet.com/hiv Vol 3 October 2016
barriers that prevent PWID from legally accessing needle and syringe programmes.9 Ukraine, with support from international partners and donors, has made substantial progress in programmes for PWID. By 2014, prevention programmes delivered by 76 local non-governmental organisations were able to reach 179 800 PWIDs each year with sterile needles and syringes and reduce HIV incidence. This value equates to 58% of the estimated number of PWID in Ukraine.10 Social networks of PWID played a crucial part in delivering these programmes and reducing vulnerability to HIV.11 Booth and colleagues4 present evidence of the efficacy of integrating peer education into existing HIV prevention programmes for PWID in Ukraine. This study is the first to assess, in a randomised controlled trial, the effect of peer-led harm reduction plus standard counselling and HIV testing (HTC) interventions versus HTC alone on reducing HIV incidence among PWID. The study was able to recruit 1200 participants and retain 90·4% at 12 month follow-up visit. In the intervention group, a reduction of HIV incidence of 0·53 (95% CI 0·38–0·76, p=0·0003) was noted. This is an impressive achievement for a risk-reduction intervention delivered by peer counsellors over five sessions within a period of 12 months. Voices and opinions of peer counsellors and peer leaders are trusted within PWID communities and provide valuable information and knowledge to influence behaviour change. Building, strengthening, and expanding low-threshold services in which peer leaders are empowered with knowledge, skills, and commodities to prevent HIV transmission is a strategic choice for curbing the HIV epidemic in eastern Europe. Extending peer-led interventions to other important areas of HIV programmes (eg, preexposure prophylaxis, adherence to antiretroviral treatment, early detection of tuberculosis) could have a substantial beneficial effect on behaviours of PWID, HIV incidence, and survival.
Published Online July 28, 2016 http://dx.doi.org/10.1016/ S2352-3018(16)30093-5 See Articles page e482
e453
Comment
Ruslan Malyuta
6
UNICEF Regional Office for Central Eastern Europe and Commonwealth of Independent States, Geneva, Switzerland [email protected] I declare no competing interests. 1
2
3
4
5
7
8
UNAIDS. Political Declaration on HIV and AIDS: On the Fast-Track to Accelerate the Fight against HIV and to End the AIDS Epidemic by 2030. New York, NY: United Nations, 2016. http://www.unaids.org/en/resources/documents/ 2016/2016-political-declaration-HIV-AIDS (accessed July 4, 2016). UNAIDS. Global AIDS update. New York, NY: United Nations, 2016. http://www.unaids.org/sites/default/files/media_asset/global-AIDSupdate-2016_en.pdf (accessed July 4, 2016). UCSDDC. National HIV/AIDS estimates. HIV Infection in Ukraine. Bulletin No. 41. Kiev: Ukrainian Centre for Socially Dangerous Disease Control, 2014 (in Ukrainian). http://ucdc.gov.ua/uploads/documents/c21991/292db485 2fd9bdcddde533c5a216ad19.pdf (accessed July 20, 2016). Booth RE, Davis JM, Dvoryak S, et al. HIV incidence among people who inject drugs (PWIDs) in Ukraine: results from a clustered randomised trial. Lancet HIV 2016; published online July 28. http://dx.doi.org/10.1016/ S2352-3018(16)30040-6. Berleva G, Dumchev K, Kasianchuk M, et al. Analytical report: estimation of the size of populations most-at-risk for HIV infection in Ukraine as of 2012 based on the results of 2011 survey. Kiev: International HIV/AIDS Alliance, 2012. http://www.aidsalliance.org.ua/ru/library/our/2013/SE_2012_Eng. pdf (accessed July 4, 2016).
9
10
11
Booth RE, Davis JM, Brewster JT, Lisovska O, Dvoryak S. Krokodile injectors in Ukraine: fueling the HIV epidemic. AIDS Behav 2016; 20: 369–76. Romanova N, Shulga L, German E. Analytical report: facts about current drug scene in Ukraine, 2nd quarter, 2014 (in Russian). Kiev: International HIV/AIDS Alliance, 2014. http://www.aidsalliance.org.ua/ru/library/ our/2014/narkoszena_rus.pdf (accessed July 4, 2016). WHO. Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. Geneva: World Health Organization, 2014. http://apps.who.int/iris/bitstream/10665/128048/1/9789241507431_ eng.pdf?ua=1&ua=1 (accessed July 4, 2016). Abdul-Quader AS. Feelemyer J, Modi S, et al. Effectiveness of structural-level needle/syringe programs to reduce HCV and HIV infection among people who inject drugs: a systematic review. AIDS Behav 2013; 17: 2878–92. WHO Regional Office for Europe. Good practices in Europe: HIV prevention for people who inject drugs implemented by the International HIV/AIDS Alliance in Ukraine. Copenhagen: WHO Regional Office for Europe, 2014 http://www.euro.who.int/__data/assets/pdf_file/0003/254352/ FINAL-Ukraine-Good-Practice-July-2014-with-covers.pdf (accessed July 4, 2016). Shahesmaeili A, Haghdoost AA, Soori H. Network location and risk of human immunodeficiency virus transmission among injecting drug users: results of multiple membership multilevel modeling of social networks. Addict Health 2015; 7: 1–13.
Heightened epidemic in men who have sex with men in Brazil Published Online August 17, 2016 http://dx.doi.org/10.1016/ S2352-3018(16)30059-5
“They always say time changes things, but you actually have to change them yourself.” Andy Warhol1
See Articles page e490
As noted in the UNAIDS Gap report,2 Brazil has the largest number of people living with HIV in Latin America and is one of 15 countries (mostly middle-income countries) that account for three quarters of the global HIV pandemic. The epidemic in Brazil remains predominantly concentrated in key populations, such as injection drug users, sex workers, and gay, bisexual, and other men who have sex with men (MSM).2 However, in the past 10 years, the number of new HIV infections has been increasing in younger people (≤25 years) and MSM.2 As has been reported in other countries,3 the AIDS epidemic in Brazil is disproportionately concentrated in MSM.4 Results from a national study4 in 2013 showed that HIV prevalence among MSM ranged from 5·2% to 23·7% in ten large metropolitan cities throughout Brazil. The overall HIV prevalence in MSM was two times higher than that estimated for female sex workers and three times higher than that for injection drug users. Additionally, half of MSM in this study who tested HIV positive were not aware of their infection.4 In The Lancet HIV, Lara Coelho and colleagues5 reported findings from their observational cohort study of e454
2224 HIV-infected individuals from the Instituto Nacional de Infectologia Evandro Chagas database. After excluding individuals who reported injection drug use or heavy cocaine use, MSM were 2·24 (95% CI 0·82–6·11) times more likely to die from AIDS-related causes than were women in the adjusted model; although this figure is not significant (p=0·114), it indicates that differences in AIDS-related rates of death between this select group of MSM and heterosexual men and women merit further investigation. Compared with women, MSM were younger, more likely to be white, and had more years of education at enrolment, and they had slightly more compromised immune status in the follow-up period. MSM were also less likely to initiate ART than were women; however, among those who did start ART, their adherence, as suggested by their viral load, was higher than that in women. The lack of use of and retention on ART was further supported by the finding that the frequency of AIDS-defining malignant disease, specifically Kaposi’s sarcoma, was more than three times higher in MSM than in women. However, even after controlling for these factors in an adjusted model, the disparity in the hazard of AIDS-related death for MSM compared with women remained unchanged. Furthermore, the increased hepatitis B virus infection among MSM in this study5 suggests the need for a www.thelancet.com/hiv Vol 3 October 2016
9
10
Newell ML, Coovadia H, Cortina-Borja M, Rollins N, Gaillard P, Dabis F. Mortality of infected and uninfected infants born to HIV-infected mothers in Africa: a pooled analysis. Lancet 2004; 364: 1236–43. Violari A, Cotton MF, Gibb DM, et al. Early antiretroviral therapy and mortality among HIV-infected infants. N Engl J Med 2008; 359: 2233–44.
11 12
Rosen S, Fox MP. Retention in HIV care between testing and treatment in sub-Saharan Africa: a systematic review. PLoS Med 2011; 8: e1001056. Mugglin C, Estill J, Wandeler G, et al. Loss to programme between HIV diagnosis and initiation of antiretroviral therapy in sub-Saharan Africa: systematic review and meta-analysis. Trop Med Int Health 2012; 17: 1509–20.
Curbing HIV incidence in people who inject drugs In June, 2016, the UN General Assembly adopted a Political Declaration On Hiv And Aids: On The FastTrack To Accelerate The Fight Against HIV And To End The AIDS Epidemic By 2030. The document noted the absence of global progress made in reducing transmission of HIV among people who use drugs, particularly those who inject drugs (PWID).1 UNAIDS estimates that between 2010 and 2015, the number of new adult HIV infections decreased or remained static in every region except eastern Europe and central Asia, where there was a 57% increase, with PWID accounting for 51% of new infections.2 Ukraine remains one of the countries hardest hit by the HIV epidemic in Europe with an estimated 238 000 people living with HIV.3 20 years after the outbreak of HIV among PWID, this route of infection remains the main force pushing the epidemic forward. In 2011, at the time of the study by Robert Booth and colleagues4 published in The Lancet HIV, an estimated 310 000 PWID lived in the country with an overall HIV prevalence of 19·7% (compared with 0·62% prevalence in the general adult population).5 The demographics of drug users, drug-use patterns, and social issues surrounding drug use in Ukraine differ when compared with other countries and regions in the world battling the problem of illicit substance use and its consequences. Most injected drugs are homemade from various ingredients and precursors, often extracted from legally available over-the-counter medicines (eg, codeine or pseudoephedrine from cold medicines), solvents, and so on. A particularly harmful form of such drug mixing is so-called krokodil,6 which is used intravenously causing health damage. Drug scenes vary depending on the availability and access to these drug precursors and ingredients in different provinces of the country.7 Needle exchange and other harm reduction services along with opioid substitution treatment are core elements of WHO guidelines to prevent spread of HIV among PWID.8 Reduction of HIV incidence among PWID requires measures to address structural www.thelancet.com/hiv Vol 3 October 2016
barriers that prevent PWID from legally accessing needle and syringe programmes.9 Ukraine, with support from international partners and donors, has made substantial progress in programmes for PWID. By 2014, prevention programmes delivered by 76 local non-governmental organisations were able to reach 179 800 PWIDs each year with sterile needles and syringes and reduce HIV incidence. This value equates to 58% of the estimated number of PWID in Ukraine.10 Social networks of PWID played a crucial part in delivering these programmes and reducing vulnerability to HIV.11 Booth and colleagues4 present evidence of the efficacy of integrating peer education into existing HIV prevention programmes for PWID in Ukraine. This study is the first to assess, in a randomised controlled trial, the effect of peer-led harm reduction plus standard counselling and HIV testing (HTC) interventions versus HTC alone on reducing HIV incidence among PWID. The study was able to recruit 1200 participants and retain 90·4% at 12 month follow-up visit. In the intervention group, a reduction of HIV incidence of 0·53 (95% CI 0·38–0·76, p=0·0003) was noted. This is an impressive achievement for a risk-reduction intervention delivered by peer counsellors over five sessions within a period of 12 months. Voices and opinions of peer counsellors and peer leaders are trusted within PWID communities and provide valuable information and knowledge to influence behaviour change. Building, strengthening, and expanding low-threshold services in which peer leaders are empowered with knowledge, skills, and commodities to prevent HIV transmission is a strategic choice for curbing the HIV epidemic in eastern Europe. Extending peer-led interventions to other important areas of HIV programmes (eg, preexposure prophylaxis, adherence to antiretroviral treatment, early detection of tuberculosis) could have a substantial beneficial effect on behaviours of PWID, HIV incidence, and survival.
Published Online July 28, 2016 http://dx.doi.org/10.1016/ S2352-3018(16)30093-5 See Articles page e482
e453
Comment
Ruslan Malyuta
6
UNICEF Regional Office for Central Eastern Europe and Commonwealth of Independent States, Geneva, Switzerland [email protected] I declare no competing interests. 1
2
3
4
5
7
8
UNAIDS. Political Declaration on HIV and AIDS: On the Fast-Track to Accelerate the Fight against HIV and to End the AIDS Epidemic by 2030. New York, NY: United Nations, 2016. http://www.unaids.org/en/resources/documents/ 2016/2016-political-declaration-HIV-AIDS (accessed July 4, 2016). UNAIDS. Global AIDS update. New York, NY: United Nations, 2016. http://www.unaids.org/sites/default/files/media_asset/global-AIDSupdate-2016_en.pdf (accessed July 4, 2016). UCSDDC. National HIV/AIDS estimates. HIV Infection in Ukraine. Bulletin No. 41. Kiev: Ukrainian Centre for Socially Dangerous Disease Control, 2014 (in Ukrainian). http://ucdc.gov.ua/uploads/documents/c21991/292db485 2fd9bdcddde533c5a216ad19.pdf (accessed July 20, 2016). Booth RE, Davis JM, Dvoryak S, et al. HIV incidence among people who inject drugs (PWIDs) in Ukraine: results from a clustered randomised trial. Lancet HIV 2016; published online July 28. http://dx.doi.org/10.1016/ S2352-3018(16)30040-6. Berleva G, Dumchev K, Kasianchuk M, et al. Analytical report: estimation of the size of populations most-at-risk for HIV infection in Ukraine as of 2012 based on the results of 2011 survey. Kiev: International HIV/AIDS Alliance, 2012. http://www.aidsalliance.org.ua/ru/library/our/2013/SE_2012_Eng. pdf (accessed July 4, 2016).
9
10
11
Booth RE, Davis JM, Brewster JT, Lisovska O, Dvoryak S. Krokodile injectors in Ukraine: fueling the HIV epidemic. AIDS Behav 2016; 20: 369–76. Romanova N, Shulga L, German E. Analytical report: facts about current drug scene in Ukraine, 2nd quarter, 2014 (in Russian). Kiev: International HIV/AIDS Alliance, 2014. http://www.aidsalliance.org.ua/ru/library/ our/2014/narkoszena_rus.pdf (accessed July 4, 2016). WHO. Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. Geneva: World Health Organization, 2014. http://apps.who.int/iris/bitstream/10665/128048/1/9789241507431_ eng.pdf?ua=1&ua=1 (accessed July 4, 2016). Abdul-Quader AS. Feelemyer J, Modi S, et al. Effectiveness of structural-level needle/syringe programs to reduce HCV and HIV infection among people who inject drugs: a systematic review. AIDS Behav 2013; 17: 2878–92. WHO Regional Office for Europe. Good practices in Europe: HIV prevention for people who inject drugs implemented by the International HIV/AIDS Alliance in Ukraine. Copenhagen: WHO Regional Office for Europe, 2014 http://www.euro.who.int/__data/assets/pdf_file/0003/254352/ FINAL-Ukraine-Good-Practice-July-2014-with-covers.pdf (accessed July 4, 2016). Shahesmaeili A, Haghdoost AA, Soori H. Network location and risk of human immunodeficiency virus transmission among injecting drug users: results of multiple membership multilevel modeling of social networks. Addict Health 2015; 7: 1–13.
Heightened epidemic in men who have sex with men in Brazil Published Online August 17, 2016 http://dx.doi.org/10.1016/ S2352-3018(16)30059-5
“They always say time changes things, but you actually have to change them yourself.” Andy Warhol1
See Articles page e490
As noted in the UNAIDS Gap report,2 Brazil has the largest number of people living with HIV in Latin America and is one of 15 countries (mostly middle-income countries) that account for three quarters of the global HIV pandemic. The epidemic in Brazil remains predominantly concentrated in key populations, such as injection drug users, sex workers, and gay, bisexual, and other men who have sex with men (MSM).2 However, in the past 10 years, the number of new HIV infections has been increasing in younger people (≤25 years) and MSM.2 As has been reported in other countries,3 the AIDS epidemic in Brazil is disproportionately concentrated in MSM.4 Results from a national study4 in 2013 showed that HIV prevalence among MSM ranged from 5·2% to 23·7% in ten large metropolitan cities throughout Brazil. The overall HIV prevalence in MSM was two times higher than that estimated for female sex workers and three times higher than that for injection drug users. Additionally, half of MSM in this study who tested HIV positive were not aware of their infection.4 In The Lancet HIV, Lara Coelho and colleagues5 reported findings from their observational cohort study of e454
2224 HIV-infected individuals from the Instituto Nacional de Infectologia Evandro Chagas database. After excluding individuals who reported injection drug use or heavy cocaine use, MSM were 2·24 (95% CI 0·82–6·11) times more likely to die from AIDS-related causes than were women in the adjusted model; although this figure is not significant (p=0·114), it indicates that differences in AIDS-related rates of death between this select group of MSM and heterosexual men and women merit further investigation. Compared with women, MSM were younger, more likely to be white, and had more years of education at enrolment, and they had slightly more compromised immune status in the follow-up period. MSM were also less likely to initiate ART than were women; however, among those who did start ART, their adherence, as suggested by their viral load, was higher than that in women. The lack of use of and retention on ART was further supported by the finding that the frequency of AIDS-defining malignant disease, specifically Kaposi’s sarcoma, was more than three times higher in MSM than in women. However, even after controlling for these factors in an adjusted model, the disparity in the hazard of AIDS-related death for MSM compared with women remained unchanged. Furthermore, the increased hepatitis B virus infection among MSM in this study5 suggests the need for a www.thelancet.com/hiv Vol 3 October 2016