HIV Prevention among Drug Users Guidance #1: Injection Heroin Use (March 2006)

Introduction
Section 104A of the Foreign Assistance Act, as amended by the U.S. Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2003 (P.L. 108-25), authorizes HIV/AIDS prevention through activities “to help avoid substance abuse and intravenous drug use that can lead to HIV infection.” Consistent with that authorization, this document provides initial policy guidance on the development of HIV/AIDS prevention-focused programs aimed at substance abusers and users of intravenous drugs, specifically those who inject heroin. It provides examples of activities for which we may consider President’s Emergency Plan for AIDS Relief (PEPFAR/Emergency Plan) funding and, likewise, examples of activities for which Emergency Plan funding would not be appropriate at this time. This document is not intended as a comprehensive policy for all HIV/AIDS prevention programs relating to substance abuse that could be contemplated under the Emergency Plan. We expect additional policy and programming guidance to evolve as new information emerges and we gain more field experience.

Substance Abuse and the Risk of HIV
Substance use, including injection drugs, is a major means of spreading HIV in many parts of the world. Injection-drug users (IDUs) everywhere are at great risk for infection with HIV, including risk associated with contracting hepatitis and sexually transmitted infections (STIs), because of past and continuing high-risk behaviors. The United Nations Office on Drugs and Crime estimates there will be a significant global increase in the production, transportation and consumption of opioids, mainly heroin. We can anticipate that increased access to these drugs will play a critical part in perpetuating the HIV/AIDS epidemic. As such, we intend to begin to address this issue with three approaches to HIV prevention, namely: 1) tailoring HIV prevention programs to substance abusers; 2) supporting, with approval from the Office of the U.S. Global AIDS Coordinator, or OGAC, substance abuse therapy programs for HIV-infected individuals as an HIV prevention measure; and 3) offering HIV-infected drug users a comprehensive HIV/AIDS treatment program to reduce the risk of transmission. Comprehensive HIV/AIDS prevention programs can help substance users stop using drugs, change their risk behaviors, and reduce their risk for acquiring or transmitting HIV infection.

1. Tailoring HIV Prevention Programs to Substance Abusers
The most effective strategy for preventing HIV/AIDS and other blood-borne infections in substance-using populations and their communities is one that decreases drug use and includes information and education, community outreach, risk reduction counseling, and substance abuse treatment. Community-based outreach for drug users should address HIV prevention, risk reduction, and substance abuse with links to appropriate care and treatment services. Prevention education should address the risks of injecting drugs and sharing syringes, and provide education and counseling on how to reduce or stop injecting drugs.

2. Supporting Substance Abuse Programs as an HIV Prevention Measure
Substance abuse programs may include behavioral models or medication-assisted treatment, or a combination of the two, and should also include case management and counseling services. Medication-assisted treatment that uses methadone, buprenorphine or naltrexone, is an effective option for treatment of heroin dependence. Heroin injectors who do not enter substance abuse treatment programs are up to six times more likely to become infected with HIV than injectors who enter and remain in treatment.^{1, 2}Many substance users are not currently in substance abuse treatment programs because of multiple factors, including the limited availability of these programs. Consequently, substantial numbers of substance users continue to use, and thus continue to be at risk for HIV and hepatitis infections. These programs should include aspects that encourage making the transition from medications to abstinence. Medication-assisted treatment can be combined with other modalities as part of a comprehensive HIV/AIDS prevention program. All prevention programs that contain medication-assisted substance abuse treatment will require prior approval from OGAC. The Emergency Plan may only support on a pilot basis prevention programs providing medication-assisted substance abuse treatment to HIV-negative individuals.

3. Offering HIV-Infected Drug Users a Comprehensive Program to Reduce Their Risk of Transmission
To reduce the risk of HIV transmission, Emergency Plan programs should offer HIV-infected heroin users a comprehensive HIV/AIDS treatment program that promotes recovery through confidential HIV counseling and testing, anti-retroviral treatment (ART), palliative care, STI and tuberculosis treatment, substance abuse treatment, and transitional services between treatment facilities and the community (e.g., care referrals, risk reduction education, job skills training, etc.). Drug users with HIV respond as well to HIV-specific therapy as do other patient groups. Studies have documented that HIV-infected drug users who receive substance abuse treatment and other health care services are more likely to reduce high-risk drug and sexual behaviors and to comply with medical regimens.

Summary
Consistent with U.S. Government policy, Emergency Plan funding may not be used to support needle or syringe exchange programs (NSEP).
Emergency Plan funds may support the following activities:

• Policy activities that encourage countries to remove barriers to medication-assisted treatment for heroin users as an important component of their national HIV/AIDS treatment and prevention plans;
• Assessments of the contribution of substance use to the HIV epidemic globally;
• Confidential, routine HIV counseling and testing in substance abuse programs;
• Community-based outreach for drug users that addresses HIV prevention, risk reduction, and substance use with links to appropriate care services;
Prevention education on the risks of injecting drugs and sharing syringes, and education and counseling on how to reduce or stop injecting drugs;
• Education of health professionals and policymakers regarding best practices for HIV prevention strategies for substance users;
• HIV treatment or referral to treatment for the HIV-infected IDU in the context of a comprehensive prevention program; and
• Substance abuse treatment programs for HIV-infected individuals, including medication-assisted treatment with methadone, buprenorphine and naltrexone. For those who are HIV-negative, the Emergency Plan can only support these programs on a pilot basis. All medication-assisted substance abuse therapy will require prior OGAC approval.

¹Sorensen JL, Copeland AL. Drug abuse treatment as an HIV prevention strategy: a review. Drug and Alcohol Dependence 2000; 59(1): 17-31.
²Metzger DS, Navaline H, Woody GE. Drug abuse treatment as AIDS prevention. Public Health Reports 1998; 113(Suppl.): 97-106.