Alcohol and drug addiction are major drivers of the HIV/AIDS epidemic in many parts of the world, but for political and ideological reasons, scientists and clinicians have tended to shy away from this area of HIV research, while governments and donors have been reluctant to fund programmes targeting addicts.
This was the theme of several presentations on the implications of drug and alcohol dependence in HIV prevention and treatment at the 5th International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention in Cape Town, South Africa, on Tuesday.
An analysis of a number of studies on the association between alcohol use and HIV in sub-Saharan Africa found that drinkers had a 70 percent higher risk of contracting HIV compared to non-drinkers.
"Programmes aimed at reducing alcohol consumption could reduce HIV infections," said Dr Saidi Kapiga of the Harvard School of Public Health, but few such programmes exist. "It's something we're just not talking about, but [alcohol] is a major driver of the epidemic."
Nora Volkow, director of the National Institute on Drug Abuse (NIDA) at the US National Institutes of Health, described addiction as a chronic brain disease mainly determined by genetics and environmental factors, but this had not prevented addicts from being highly stigmatized, and HIV-positive addicts from being doubly stigmatized.
Drug addiction has many serious health consequences, including a greater risk of infectious diseases such as HIV, Volkow said. "You can't cure drug addiction, but you can treat it, and you should ... treatment of drug addiction is a way to prevent HIV."
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Behavioural therapy and substitution treatment using methadone or similar drugs to help users overcome their addictions and lower their HIV risk are unavailable in most settings, or form part of pilot programmes that are never scaled up or integrated into public health care systems.
Eastern Europe and Central Asia have experienced an epidemic in drug use since the 1990s, with the result that injecting drug users now make up 85 percent of people living with HIV in some parts of the region.
Konstantin Lezhentsev, of the Harm Reduction Programme run by the Open Society Institute, said a few countries in Eastern Europe had begun offering substitution treatment, but high levels of stigma, repressive drug laws, a lack of guidance on implementation, and a reluctance by medical professionals, government and NGOs to address the problem meant that such programmes rarely got beyond the pilot stage.
In South Africa a colossal increase in mephamphetamine use since 2003 is contributing to the spread of HIV in a country that already has the largest burden in the world. Charles Parry, of the Medical Research Council, said users experience a sense of euphoria, heightened self-confidence and sexuality that can lead them to having multiple sexual partners and sharing needles.
Substitute medications to treat methamphetamine addiction are still in development, but long-term behavioural therapy could be effective. Despite the evidence that "methamphetamine treatment equals HIV prevention", said Parry, "we haven't really progressed beyond research studies; we need to operationalize them by implementing initiatives we know work."
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