By Dr. Nora Volkow, Director, National Institute on Drug Abuse, National Institutes of Health
Since the HIV epidemic began, drugs of abuse have played a key role in its expansion, both in the United States and internationally. Worldwide, roughly 16 million people inject drugs, with HIV prevalence rates among injection drug users varying widely by geographic area—from 25% to nearly 90% across particularly hard-hit cities in regions of Eastern Europe and Central Asia, for example. That said, non-injection drug use can also increase the likelihood of HIV transmission through altered judgment and greater risk taking from addiction or drug-induced intoxication. That is why the National Institute on Drug Abuse (NIDA) believes that preventing HIV transmission among drug abusers can have a dramatic impact on improving global health.
Research has demonstrated the effectiveness of a variety of strategies in reducing HIV transmission among drug users, such as drug abuse treatment, risk reduction measures, community outreach, and expanding access to HIV treatment. Indeed, we know that drug abuse treatment is HIV prevention. Use of opioid agonist medications like methadone and buprenorphine have been shown not only to reduce drug use, but HIV risk as well. Still, many countries have not provided access to these therapies. Now a new medication, Vivitrol, may offer a more acceptable alternative, since it is the first non-narcotic, non-addictive, extended-release medication for the treatment of opioid dependence. An injectable form of the opioid antagonist naltrexone, Vivitrol, has garnered impressive results in treating opioid addiction in clinical trials in Russia, and has recently received approval by the Food and Drug Administration for treating opioid abuse in the United States. Like the opioid agonist therapies, by reducing drug use, Vivitrol stands to also reduce HIV risk.
Just as drug abuse treatment can prevent HIV infection, so can HIV treatment prevent further HIV spread. Research shows that broad-based HIV screening and early initiation of HAART can reduce viral load and HIV incidence at the population level. To this end, a very promising approach, termed “Seek, Test, Treat, and Retain” (STTR), involves reaching out to high-risk, hard-to-reach groups who have not recently been tested (seek), providing HIV testing (test), initiating treatment for those who test positive (treat), and monitoring and maintaining them in HAART therapy (retain). NIDA is supporting research to further test this strategy in populations at greatest risk, who generally remain outside the treatment loop, such as drug users or those in the criminal justice system. To the latter, NIDA also expects STTR to improve the provision and maintenance of HAART following community reentry, when treatment lapse and viral load rebound can heighten risk of HIV transmission.
Finally, we must act now, joining forces to integrate strategies and share the best knowledge we have to transform the public health. Scientific evidence clearly shows that a variety of interventions can prevent HIV transmission, but implementing a combination of prevention strategies that have been adapted for specific contexts is our best hope for eliminating HIV.