Paradoxes and Problems in Preventing HIV Infection among Injecting Drug Users and Their Sexual Partners in Eastern Europe and Asia Don C. Des Jarlais, Ph.D. Director of Research Baron Edmond de Rothschild Chemical Dependency Institute Beth Israel Medical Center New York

Potential for Very Rapid Spread of HIV among Injecting Drug Users--Incidence of 20% to 50% Per Year New York City Bangkok Eastern Europe, Russia, Newly Independent States Some areas in Asia and South Asia

Effective Prevention--National Institutes of Health Consensus Development Conference Syringe access/exchange, e.g., New York City (Des Jarlais, et al.) Community Outreach, e.g., Chicago (Weibel, et al.) Drug Abuse Treatment (Methadone), e.g. Philadelphia (Metzger, et al.) Reductions of 70% to 83% in rates of new HIV infections

Successful Prevention at the Community and Country Level United Kingdom Australia Many individual cities, e.g., Tacoma, WA

Reversing High Seroprevalence Epidemics among IDUs New York City

Will HIV Prevention Programs for IDUs Work in Developing Transitional Countries?

Sharing/Risky Injection Behaviors of Central and Eastern European Syringe Exchange Participants N=595

Sharing/Risky Injection Behaviors of Russian Syringe Exchange Participants N = 1,076

Current Prevention Programming for IDUs in Eastern Europe and Central Asia, South Asia and East Asia Outreach/Syringe Exchange –184 programs in Eastern Europe, Russia and Central Asia –A few programs in rest of the area Methadone Maintenance –approximately 7000 patients –50% in Slovenia and Croatia –None in Russia and China

Coverage at the Local Level “Criterion” of 60% of local IDU population Probably very few current programs reach this level

Prevention of Sexual Transmission of HIV from Injecting Drug Users to Non-injecting Heterosexual Partners Recent meta-analysis of 33 methodologically rigorous studies (conducted by CDC, Semaan et al. 2002) Some programming is modestly effective compared to no programming Components of effective programming cannot yet be identified Likely issues in adapting/translating to developing countries, e.g., levels of stigmatization and HIV drug use

Possibility that HIV among IDUs Will Lead to Generalized HIV Epidemics Appears to have occurred in Manipur, India Use of commercial sex workers by male IDUs Participation in commercial sex work by female IDUs High prevalence of other STDs facilitating HIV transmission

Issues for Consideration Stigmatization of drug use and HIV-denial of problems Simultaneous epidemics of HIV and injecting drug use Policy support for effective HIV prevention programs Local adaptation Support on the streets-lack of police interference Coverage (60%? at local level) Sustainability