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HIV incidence has been slowly declining in Russia during the last 5 years. At the beginning of the epidemic, transmission occurred mainly among sex workers and people who inject drugs (PWID), but now infections are spreading among the community at large. I have chosen to comment on 2 presentations from CROI 2021 addressing HIV among PWID. Although both studies were conducted in India, I hope we can learn from their experience and apply the lessons to other regions of the world where HIV transmission continues at high rates among PWID, including where I practice medicine in Russia and other regions of Eastern Europe.
Injection Networks and HIV Prevention Services Among PWID
New HIV infections continue to increase among PWID in India, and PWID often do not use available strategies to prevent HIV infection. In addition, PWID do not live in isolation and are often connected to networks of other PWID with whom they may share injection equipment and information. In the first study I review, researchers looked for relationships between characteristics of PWID networks and recent engagement with HIV prevention strategies, including HIV testing in the previous 6 months, use of medication for the treatment of opioid use disorder, and the use of syringe services in the previous month. The researchers recruited 11,745 PWID from 12 cities across India who were aged 18 years or older and reported injection drug use in the past 2 years. After HIV testing, the analytical sample consisted of 7380 HIV-negative individuals who reported active injection drug use in the previous 6 months. They completed surveys about their networks and their use of prevention services. The average age of survey respondents was 28 years and 98% were male. The median network size was 3, but 17% reported more than 10 injection partners. Only 0.9% shared equipment with a partner with HIV infection. The number of PWID who availed themselves of HIV prevention strategies was small: 15% had an HIV test in the past 6 months, 20% received medication for the treatment of opioid use disorder, and 27% used syringe services in the previous month. Only 3% had used all 3 strategies.
The researchers found that the size of the network was not associated with HIV testing. Injecting with >10 partners vs ≤1 partner was associated with decreased use of medication for the treatment of opioid use disorder and increased use of syringe services. Sharing equipment with a partner with HIV was associated with a recent HIV test. It seems to me that use of HIV prevention services may be most related to an individual’s perception of their own risk, for example, sharing equipment with a partner with HIV was associated with HIV testing. Perhaps better education on HIV risk among PWID might result in greater use of prevention services.
COVID-19 Pandemic Impact on Access to HIV Services for Key Populations
Beginning in 2013, India established integrated care centers targeting PWID in 8 cities. The centers provide an array of services including HIV counseling and testing, STI testing, and linkage to and monitoring of antiretroviral therapy (ART) from government facilities. In a second study from India, researchers evaluated the impact of COVID-19 on service utilization at these centers, comparing the prepandemic months of January to February 2020 with the pandemic months of March to July 2020. The investigators also assessed the medication possession ratio (MPR), defined as the percentage of days in a month that a client had an available dose of ART, from February through July 2020.
The national lockdown began in India on March 24, 2020, and on April 14, 2020, it was extended through May 2020. National restrictions were lifted on May 30, 2020, although local restrictions remained in force. Service utilization declined sharply in mid-March, dropping to approximately 25% of capacity. Among PWID, HIV testing decreased by 90%. Although testing increased somewhat when the restrictions were lifted, the levels had not returned to the prepandemic levels by mid-July 2020. For PWID with HIV, the median MPR declined 60% (from 97% to 40%) from February to April 2020. The MPR continued to decline after April, reaching its lowest level—16%—in July 2020.
In India, the COVID-19 pandemic severely disrupted HIV testing and treatment services for PWID and represents a setback in efforts to contain HIV transmission. I believe other countries observed similar disruptions in HIV services and are likely to have experienced a similar setback in controlling the HIV epidemic.
How has the COVID-19 pandemic affected HIV prevention and treatment services for PWID in your region? What mitigation strategies have or have not been helpful to reduce the impact of the pandemic on underserved or vulnerable populations in your clinical practice? Join the discussion by posting a comment sharing your experiences.