Introduction

Sharing, or use, of contaminated needles is a very effective way of spreading HIV. Since injecting drug users often have close links and commonly share injecting equipment, HIV can spread very rapidly among them.

In global terms, drug injection, because of the health and social problems associated with it, remains the biggest cause of morbidity and mortality resulting from the abuse of drugs (see E/CN.7/2000/4, sect. IV.A). Injecting drug use is the main or a major mode for the transmission of HIV in many countries of Asia, Europe, Latin America and North America. In some countries, including Bahrain, Georgia, Italy, Kazakhstan, Portugal, Spain and Yugoslavia, over one half of all AIDS cases are attributed to injecting drug use and, in Argentina and the Islamic Republic of Iran, more than two fifths. While precise figures can be difficult to obtain, it is clear that HIV can spread through drug-using populations with remarkable speed and can stabilize at very high rates. For example, HIV infection among injecting drug users in various cities in Ukraine rose from virtually zero in 1994 to between 31 and 57 per cent in less than two years. In 1999, there was a massive outbreak of HIV infection among injecting drug users in Moscow, with more than three times as many new cases of HIV reported in that year than in all previous years combined. HIV prevalence rates ranging between 30 and 70 per cent have been found among injecting drug users in Argentina, Brazil, India, Spain, Thailand and the United States of America (Puerto Rico). Risk behaviour in these populations remains common (UNAIDS, 2000).

While in both Europe and the United States higher levels of heroin abuse have recently been accompanied by an increase in non-injecting modes of transmission, the number of countries reporting the existence of injecting drug users and HIV infection among them continues to grow. In 1998, 136 countries reported injecting drug abuse, a significant increase compared to 1992, when 80 countries reported such abuse. In addition, 93 countries (68 per cent of those reporting) reported that HIV infection had been identified among drug injectors (E/CN.7/2000/4, sect. IV.A). This illustrates a worrying trend: the diffusion of injecting into an increasing number of developing countries and countries in economic transition, in which the behaviour was often virtually unknown.

An obvious concern in increased rates of injection relates to blood-borne infection in general and HIV infection in particular. Extrapolations from case data on AIDS suggest that the cumulative number of injecting drug users infected with HIV could be around 3.3 million (to 1997). Such estimates should be treated with caution, since both the true size of the global population of injecting drug users (estimated at 5 million in 1992) remains unknown, as does the rate of HIV infection among them (E/CN.7/2000/4, sect. IV.A).

HIV risk among drug users arises not only from injecting. Many types of psychoactive substances, whether injected or not, including alcohol, are risky in that they affect an individual’s ability to make decisions about safe sexual behaviour. Studies have associated crack-cocaine use with elevated levels of high-risk sexual behaviour, for example in the United States, where crack-cocaine users account for an increasing proportion of AIDS cases.

Numerous studies have also found that drug users are disproportionately likely to be involved in the sex industry or to engage in high-risk sexual activity. Drug-injecting also contributes to an increased incidence of HIV infection through the transmission of the virus to the children of drug-injecting mothers, and through sexual contact between drug injectors and non-injectors.

Deciding on the implementation of intervention strategies to prevent HIV in injecting drug users is one of the most urgent questions facing policy makers. Studies have demonstrated that HIV transmission among injecting drug users can be prevented and that the epidemic has been slowed and even reversed in some cases. HIV preventive activities that have had some impact on HIV prevalence and risk behaviour offer a combination of AIDS education, access to condoms and clean injecting equipment, counselling and drug abuse treatment.

Meeting the challenges of dealing with drug abuse and HIV/AIDS requires institutional commitment at the national and local levels, the involvement of the wider community in planning and implementation, adequate needs assessment, the provision of training programmes for the acquisition of new skills, increasing the availability of a wide range of services, evidence-based practice, and the establishment of monitoring and evaluation systems.

In the present booklet, an attempt is made to capture details of a range of practices, in order to provide useful lessons and offer references for those working in the field of drug abuse and HIV/AIDS prevention. Owing to time and space constraints, the entries in the booklet represent only some of the many reports and project information that were received. It is hoped that the lessons learned will be widely shared so as to contribute to the development of ethically sound and effective responses to the issue of drug abuse and HIV/AIDS prevention in the region.

In its first three chapters, the booklet presents 20 case studies, grouped according to the focus of the projects concerned: fieldwork, political mobilization and strategy development, and training and networking, each with an overview of lessons learned in the respective fields. Overall lessons learned and challenges for the future are summarized in a final chapter that is aimed at policy makers.

The case studies come from 11 countries in Eastern and Central Europe and Central Asia (Belarus, Bulgaria, the Czech Republic, Hungary, Kazakhstan, Lithuania, Poland, the Russian Federation, Slovakia, Slovenia and Ukraine) and provide detailed information for practitioners on the current policies and practice of HIV prevention among injecting drug users. They illustrate how both drug abuse and HIV preventive strategies and intervention concepts have been introduced into specific national and local contexts, and the responses to a number of important challenges.

Many case studies reach across the topics of fieldwork, policy development and networking since, in practice, these are closely linked. This applies in particular to national pilot projects, the objectives of which include both carrying out fieldwork for a target group in a certain geographical area and providing input to national policy development and training. Despite many common elements in intervention policies and strategies, the collection of case studies shows the different adaptations that occur in response to local contexts, and illustrates that the relative success of HIV preventive interventions is inextricably linked to the social, cultural and political contexts in which they occur (Rhodes, 1996).

Chapter I focuses on fieldwork projects, illustrating in 10 case studies how the main HIV preventive interventions targeting injecting drug users were put into practice, and how hidden target populations were reached. Experiences from outreach projects, peer education and low-threshold services (see glossary) show how supportive local conditions and clear strategy frameworks for community mobilization can contribute to the success of HIV prevention efforts. Further, the chapter gives examples of the work undertaken with specific target groups (sex workers and ethnic minorities) and highlights the practice of local cooperation between health and law-enforcement services, and state and non-governmental agencies. One example shows how the primary public health-care system can become a partner in the provision of substitution treatment to drug users, and thus contribute to reducing their stigmatization.

Chapter II contains five case studies that illustrate the process of political mobilization and national strategy development. Addressed, among others, are such questions as how all stakeholders can become actively involved in HIV/AIDS prevention among injecting drug users and the roles that a supportive legal framework and intersectoral cooperation can play. The example of Poland shows the development and impact of the inclusion of programmes to facilitate access to sterile injecting equipment in the context of a strategy to prevent the spread of infection among injecting drug users. Another example documents typical obstacles to implementing HIV prevention activities in a low-prevalence context and describes which steps were taken to achieve consensus and support among the main stakeholders.

Chapter III gives five examples of training and networking projects, which play a major role as effective and cost-efficient contributions to information sharing, capacity-building and resource mobilization at the regional and national levels.

Chapter IV summarizes the lessons learned and the specific challenges with which projects for HIV prevention among injecting drug users in the region had to cope. The chapter also draws on discussions held among representatives of projects at a meeting convened by UNDCP at Minsk, from 13 to 15 July 2000, as part of the preparation of the present booklet.

References

Rhodes, T. 1996, “Individual and community action in HIV prevention: an introduction”, in Rhodes, T. and Hartnoll, R., AIDS, Drugs and Prevention, Routledge, London and New York, pp. 1-9.

UNAIDS 2000, Report on the Global HIV/AIDS Epidemic”, UNAIDS, Geneva.