AN AIDS-FREE GENERATION

Despite great strides in treating HIV, and despite effective prevention strategies that have reduced its spread among many populations, about 50,000 new cases of HIV are still diagnosed each year. December 1, World AIDS Day, is a good time to remember not only how far we have come since HIV first appeared three decades ago, but also the obstacles that still stand in the way of creating the “AIDS-free generation” that Secretary of State Hillary Rodham Clinton has called on the world community to achieve.

One of those obstacles is drug abuse, which has been closely intertwined with the epidemic since the start. A third of the 1.2 million Americans living with HIV are current drug users, and most have a history of illicit drug use. One fifth of those with HIV don’t know they have it. All forms of drug and alcohol abuse facilitate the spread of HIV by making risky behaviors such as unsafe sex more likely, and use of injection drugs compounds the risks through the danger of sharing contaminated needles. Injection drug users (IDUs) are at greatly increased risk for contracting HIV compared to the rest of the population, and unfortunately they are also the hardest to reach with testing and treatment.

One of the goals set forth in the National HIV/AIDS Strategy is increasing access to care and improving health outcomes for all Americans living with HIV, and in unveiling the President’s Emergency Plan for AIDS Relief (PEPFAR) Blueprint this week, Clinton emphasized the need to break down barriers to HIV services for key populations worldwide, including IDUs. To this end, NIDA actively funds research to develop and test interventions among drug users, one of the most vulnerable and inaccessible populations. Among other areas of research, we are actively studying how to widely and successfully implement the seek, test, treat, and retain (STTR) strategy in substance abusing populations: Seeking out high-risk, hard-to-reach substance abusers, testing them for HIV, beginning treatment for individuals who test positive, and retaining those individuals in treatment and monitoring their care.

But strategies like STTR can only work when those who are tested and referred to treatment actually receive it. Unfortunately, IDUs with HIV often do not receive the highly active antiretroviral therapy (HAART) that is the standard of care for people infected with the virus. A NIDA-funded study published earlier this year in the Journal of the International AIDS Society revealed the scope of this terrible treatment disparity. Although Federal guidelines at the time the study was completed strongly recommended administering HAART to any HIV-infected patient with a CD4+ cell count under 350 cells/mm3, nearly half of the 662 American and Canadian HIV treatment providers surveyed in the study indicated they would defer HAART for such a patient if he or she occasionally injected drugs, and over two thirds of the providers indicated they would defer treatment if the patient injected every day. Providers were even more likely to defer HAART for drug users with lower levels of infection. (You can learn more about the study here.) Current U.S. guidelines recommend that all HIV-infected patients should receive the treatment, regardless of their CD4+ cell count.

Some providers’ think that IDUs are less likely to benefit from HAART because they will not adhere or respond to the treatment and that, if treated, they may develop resistant viral strains. Research has not supported these concerns. Studies have found similar survival rates and rates of drug resistance between IDUs and non-IDUs given the treatment. The challenge however is to provide treatment for the substance use disorder alongside HAART, in order to increase the likelihood of treatment compliance. HAART not only improves the patient’s outcomes but also reduces his or her ability to spread the disease to others, which highlights the importance of interventions that target substance abusers rather than excluding them. There is no possibility of achieving an AIDS-free generation as long as IDUs with HIV do not receive the same treatment non-IDUs would receive.

World AIDS Day is the perfect occasion to be reminded of the millions who have been affected by HIV/AIDS, and to renew our commitment to an AIDS-free generation by expanding HIV testing and treatment and working to overcome the misconceptions and stigma that stand in the way of treating individuals suffering from a substance use disorder.