2. Allocative efficiency (the allocation of resources to maximize health impact) of HIV programmes has been extensively studied in all regions of the world. In countries with substantial epidemics among people who inject drugs, analyses have consistently shown that investment in harm reduction programmes for people who inject drugs are part of the optimal mix of interventions to minimize new HIV infections and deaths. By prioritizing needle-syringe programmes, opioid substitution therapy and anti-retroviral therapy, countries could improve coverage and achieve fewer new infections and deaths among people who inject drugs. This will also reduce new HIV infections among sexual partners of people who inject drugs and the wider population.
- Harm reduction
3. Country case studies show that high coverage of programmes for people who inject drugs including needle and syringe programmes and opioid substitution therapy were followed by substantial reductions in new HIV infections. Mathematical modelling suggests that scaling up proven interventions including needle syringe programmes, opioid substitution therapy and anti-retroviral therapy as part of a package of related health services would represent a major step towards ending AIDS as a threat to public health by 2030. Prioritizing these programmes now is also an investment, which will substantially reduce future health care cost, recognizing that every new HIV infection implies future cost for life-long treatment of HIV and opportunistic infections. To maximize return on investment, it is therefore important for countries to review spending on HIV, health and wider drug control programmes to ensure that resources can be reallocated to evidence-based interventions.
- Harm reduction
4. In addition to evidence-based prioritization, countries can enhance the effect of HIV prevention and treatment for people who inject drugs by improving implementation efficiency. Reviews have shown that cost for procurement of drugs such as methadone, buprenorphine and anti- 4 retroviral can be substantially reduced through enhanced price comparison, price negotiation, international procurement and use of generic suppliers. Optimized models of care including standard operating procedures ensure that service provider interactions with clients focus on core services. Increasing access to services, through removing barriers and strengthening effective linkages between services, can contribute to optimal utilization of staff and site capacity, which will improve economies of scale and reduce cost. Increased domestic financing of programmes for people who inject drugs requires simultaneous efforts to build mechanisms and capacities for contracting civil society organizations providing outreach and performance management of programmes. Good governance principles, quality assurance, and best clinical practices should be consistently applied.
- Harm reduction
- Civil society engagement
5. In countries where we have conducive policies, adequate resource allocations, access to needle and syringe programmes, opioid substitution therapy and antiretroviral therapy, great progress has been made in reducing HIV transmission among people who inject opiates. The field now needs to more fully address the challenges of HIV prevention and treatment for injecting and non-injecting users of stimulant drugs: cocaine and amphetamine type stimulants (ATS). Additionally, there are emerging drugs such as mephedrone and other new synthetic drugs that may create risks for HIV transmission.
- Harm reduction
7. It is difficult to quantify the exact risk of stimulant use in increasing HIV infection. But the preponderance of the evidence points towards a positive association between stimulant use, sexual and injecting risk behaviours and HIV infections. A particular problem is the lack of scalable drug dependence treatment for stimulant use disorders. We have successful examples of reducing HIV transmission associated with stimulant use including crack-cocaine epidemics and cocaine injecting epidemics. New prevention strategy such as Treatment as Prevention (TasP) for people who use drugs living with HIV should be implemented to reduce HIV transmission in this key population. Gaps in the literature need to be acknowledged such as the lack of cohort studies, lack of focus on women and minorities, few studies from lower and middle income countries, few studies on new prevention approaches, such as Pre-exposure Prophylaxis (PrEP) for men who have sex with men using stimulant drugs, scalable drug dependence treatment approaches and use of social media.
- Harm reduction
8. Consistent use of antiretroviral therapies among people living with HIV/AIDS who use drugs improves the immune response. Among opioid dependent people living with HIV, methadone maintenance therapy (MMT) reliably increases adherence to antiretroviral therapy, even among homeless individuals. If adherence to antiretroviral therapy is maintained, the use of cocaine or methamphetamine among men who have sex with men living with HIV does not reduce the effectiveness of antiretroviral therapy (ART). All people who use drugs and are living with HIV require access to antiretroviral therapy.
- Harm reduction
10. Multi-faceted and multi-level approaches are required to support access and adherence to ART among people who use drugs living with HIV, including integrated ART, opioid substitution therapy and other evidence based drug dependence treatment, supportive housing and opportunities for employment and alternatives to conviction and punishment. Increasing access and adherence to ART will require health-focused drug policies based on evidence and human rights of people who use drugs.
- Harm reduction