Interview with Dr. Cristiana Oprea on the International Day against Drug Abuse and Illicit Trafficking

On the occasion of the International Day against Drug Abuse and Illicit Trafficking, which aims to foster a global action to counter drug abuse, the EACS secretariat interviewed Dr. Cristiana Oprea, the Head of the HIV Department at Victor Babes Clinical Hospital for Infectious and Tropical Diseases in Bucharest, Romania. Dr. Cristiana Oprea’s work is focused on HIV and opportunistic infections (tuberculosis and neurological complications), co-infections with viral hepatitis in people who inject drugs (PWIDs), and standards of care for HIV and co-infections in Eastern and Central Europe.

What are the links between HIV infection and injecting drugs?

People who inject drugs (PWIDs) are at higher risk of acquiring infections transmitted by parenteral mode, mainly HIV and hepatitis C, B, and D, by using and sharing unsterile syringes and needles and drug injecting paraphernalia. Needles and other injecting equipment used by an HIV-positive person can contain blood and HIV can survive in a used syringe for up to 42 days.

According to UNAIDS data, there is a 22 times higher risk of acquiring HIV among PWIDs and in 2018, 12% of the total new HIV infections were among PWIDs.

Regarding the distribution of new HIV infections by key populations, PWIDs account for 41% in countries from Eastern Europe and Central Asia.

Injecting drug use can also be associated with a higher HIV transmission by sexual mode. Being under the influence of substances is a risk factor for engaging in high-risk sexual behaviours (unprotected intercourses with multiple partners, trading sex for money and drugs) and, additionally, for poor adherence to antiretroviral treatment.

According to CDC, sharing needles is the second riskiest behaviour for HIV transmission. An HIV-negative person has a 1 in 160 chance of getting HIV each time they use a needle previously used by an HIV-positive person.

What are the main barriers preventing PWIDs from accessing HIV testing?

HIV testing plays a crucial role in the fight for HIV prevention. In some Central and Eastern European countries HIV testing is limited to centres for harm reduction or NGOs who provide rapid HIV and hepatitis testing at drop-in and outreach units. However, there are some obstacles to access adequate testing services, such as fear of stigma and discrimination from both the medical staff and family/friends, lack of awareness regarding the risk of HIV transmission by injecting drug use, homelessness and the absence of a family to support you, lack of health insurance and identity cards, low socio-economic status with limited access to health services. In some countries, there is also a low interest and involvement of local authorities to implement efficient preventing and testing services for persons from vulnerable populations and a multidisciplinary approach for the management of PWIDs is missing. Furthermore, some of the PWIDs are refusing to be tested for psychological reasons, they claim to prefer to ignore their status than confronting such difficult information.

What is the percentage of PWIDs tested HIV (+) that are on cART compared to other groups? What are the challenges of PWIDs treatment adherence?

Data on the continuum of HIV in Europe in 2018 showed a lower percentage of virally suppressed in the category of PWIDs (51%) compared to all the people living with HIV (71%).

The proportion of HIV-infected PWIDs who are on cART (combined antiretroviral therapy) varies considerably depending on the geographical region and the access to treatment in different parts of the world.

On the health care systems side, the main challenges of PWIDs treatment adherence are the limited access to ART, poor access to general health services due to social barriers and inefficient health care systems, in particular in some Eastern European countries, where injecting drug use represents the main mode of HIV transmission. Fear of non-adherence to treatment, drug-drug interactions, neuropsychiatric disorders associated with substance addiction, determined a high number of physicians to delay cART initiation in patients from key populations, including PWIDs.

The challenges of PWIDs for treatment adherence include treatment interruptions or failure due to: active injecting drug use, multiple incarcerations and limited access to treatment during imprisonment, limited access to opioid substitution treatment, lack of integrated care (for HIV and injecting drug use), lack of social support, housing or belief in treatment effectiveness.

For example, in Romania, about one-third of PWIDs are undetectable, one-third have a medium adherence and the rest usually abandon cART. PWIDs on methadone are afraid of withdrawal if they are using some classes of antiretrovirals and therefore they choose to discontinue cART.

Health providers' attitude towards PWIDs and their lack of awareness on the matter is also a problem. Drug addiction is often considered as morally wrong and not treated as a medical disorder.

HIV index score for predicting HIV care retention was published in 2019. Stigma, depression/anxiety drug, and alcohol use harm retention in care, while adherence, attending an appointment, and viral suppression have a positive effect.

How do criminalization and punitive laws against PWIDs affect their risk of contracting HIV?

In some countries, PWIDs are afraid to self-disclose because of criminalization and punitive laws. Therefore, they don’t access needle exchange programmes, even if they are available.

The criminalization of behaviours seen as socially unacceptable (drug-related issues, sex work, homosexuality, etc.), corruption, as well as the inefficient criminal justice system and the lack of non-custodial measures for dealing with crime in many parts of the world, led to extreme overcrowding in prisons, which increased the number of PLWH incarcerated globally. Prisons have higher rates of drug addiction, infectious diseases, including HIV and viral hepatitis, as well as neuropsychiatric disorders.

Usually, among PWIDs there is a frequent move between community and prisons (for short periods of imprisonment), leading to a higher risk of transmitting infectious diseases and addiction problems from prison to the community population. A vicious circle is thus created.

According to ECDC data, the proportion of HIV and viral hepatitis infections is greater among individuals in prison than among the general population. Does incarceration pose a higher HIV and hepatitis risk for PWIDs? Why?

HIV prevalence in prisons is several times higher compared to the general population due to the great rate of HIV among incarcerated injecting drug users, as well as the proportion of prisoners convicted for drug-related offences. As a general issue, prison populations include individuals with a higher risk for achieving HIV, HCV, HBV or TB due to prisoners’ background (alcohol abuse, poverty or living in minority communities with poor access to health care services) and the adoption of high-risk behaviours in prisons, like injecting drug use, including sharing needles, razors, or other injecting equipment, tattooing, and even practicing unsafe sexual behaviours. In addition, prisons are generally places with low levels of hygiene and reduced access to harm reduction programmes.

History of shared drug injection was more often reported by PWIDs inside prison comparing to those from outside prison, suggesting a higher risk for HIV and viral hepatitis infections. The length and number of incarcerations also play a role in influencing the risk of infections.

A lot of PWIDs continue injecting drug use during imprisonment, maintaining often the same level of use. Moreover, prison is also a place where drug use is initiated, often due to peer pressure or as a method for tension release and for coping with the fact of being incarcerated in an overcrowded and often violent environment.

As reported by ECDC statistics, drug injection appears to be one of the main reported HIV transmission modes in Eastern Europe. How can you explain that?

HIV prevalence in Eastern Europe registered an ascending trend during the last years, mainly due to injecting drug use. This is as a result of the poor access to harm reduction programmes in this part of the world, including needles and syringe programmes and opioid substitution therapy. Eastern European countries have also limited access to HIV diagnostic tests, antiretroviral treatment, and adequate HIV care. PWIDs from this region have to face barriers to accessing HIV prevention and treatment, which further increase their vulnerability. The spread of HIV is also facilitated by marginalisation and stigmatisation, which affects PLWH, including those from key populations (PWIDs, migrants, or prison inmates). Unfortunately, local authorities from these countries didn’t understand the importance of the problem and its impact on public health and failed to combat this epidemic. It is of particular interest to look at the situation on the matter in three countries located in this region: Romania, Russia, and Ukraine.

In the last decade, in Romania and some other countries from Eastern Europe (Ukraine, Moldova), the HIV epidemic was fueled by the frequent use of a new type of psychoactive injectable drugs, with effects similar to those produced by amphetamines. These are derived from cathinone and are a mixture of chemical powders such as mephedrone, methylenedioxypyrovalerone (MDPV), 5‐MeO‐DALT, phenethylamine, and benzopyrene. They are cheaper than heroin, but highly addictive requiring multiple injections (up to 10 - 15 times/day); thus, the risk of acquiring viral infections with their use is very high.

In Romania in 2013, 31% of the new HIV infections were reported in PWIDs but the percentage decreased progressively to 11% in 2019.

Russia had to face one of the biggest HIV epidemics, probably due to the failure of the implementation of efficient harm reduction programmes among PWIDs. An important factor in the unfolding epidemic has been the rise of injecting drug use since the 1990s. After the collapse of the Soviet Union, injecting drug use registered an alarming increase, especially among young men. The increased accessibility and affordability of illicit drugs, mainly opiates, traded from Afghanistan, and Central Asia via the so-called “northern route” facilitated the rapid spread of injecting drug use. Since then, Russia became an important place in the illegal drug market. As expected, the rise in injecting drug use caused a significant increase of HIV and viral hepatitis in PWIDs. However, harm reduction programmes were limited in Russia and their implementation was insufficient to reduce the spread of the infection.

Access to the antiretroviral treatment has been limited for all PLWH, with PWIDs being more affected by this form of discrimination.

Finally, for what concerns Ukraine, even if there have been some efforts to limit the spread of HIV infection, the military conflicts and subsequent internal problems increased the HIV vulnerability among key populations. Opioid substitution treatment is available in Ukraine since 2004, and the authorities tried to support prevention programmes for PWIDs. However, PWIDs in Ukraine still had to face multiple barriers to access adequate health care services, including stigmatisation, or limited access to antiretroviral treatment during imprisonment. The military conflicts affected all these efforts and the harm reduction programmes were difficult to be implemented in some parts of the country, a fact that led to an uncontrolled HIV spread among PWIDs.

Do you have any suggestions for effective prevention of HIV transmission among PWIDs?

In my opinion, there is still an urgent need to implement on a larger scale efficient and appropriate programmes to lower HIV and HCV spread among PWIDs.

Integrated, collaborative, multidisciplinary approaches to healthcare for PWIDs combined with intensive outreach initiatives would be essential. Some important measures would include: regularly screening for HIV and HCV, intensify needle and syringes exchange programmes, access for all to opioid substitution treatment, removing all the barriers to access cART, optimising retention in care by facilitating rapid initiation of cART, integrate HIV, HCV, TB, addiction and mental health care, partnering with local NGOs for outreach initiatives and peer support networks, education and medical counselling to increase adherence to cART, availability of pre or post-exposure prophylaxis, innovative patient-centred approaches, strong socio-psychological support, and social reintegration after the release from prison, psychotherapy and behavioural health services access and lack of criminalization.