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6 –
Daily Update
– DAY ONE/TWO – Sunday 11 and Monday 12 May 2008
THERE ARE NOW
an estimated 2.4 million people in the WHO
European Region living with HIV, which is a substantial public health
challenge by anyone’s standards. However, poor surveillance, gaps
in knowledge and misunderstandings around transmission routes
are compounding the problem.
In Eastern Europe, the epidemic is spreading most rapidly
among the male injecting drug population and their sexual partners.
What’s more, in some areas with high infection rates, these
surveillance and epidemiological ‘blind spots’ mean that effective
prevention measures can be minimal.
So is transmission in these areas primarily through injecting drug
use? ‘When we’ve done further studies we’ve found that many of
the women who report heterosexual transmission of HIV have a
history of injecting,’ says Dr Jeffrey Lazarus of the World Health
Organization (WHO). ‘It means we’ll never know how they got
infected, but knowing how difficult it is to acquire HIV sexually and
how easy it is from a contaminated needle, you don’t need a PhD.’
Co-infection with hepatitis C is also a serious and growing
concern. As injecting drug users are often referred to as an
‘invisible population’, could this be categorised as an ‘invisible
epidemic’? ‘I would refer to hepatitis C as a hidden epidemic –
there’s an agreement on that, apart from among the people who
haven’t figured out that it is an epidemic yet or are in denial. But it
is one, and a serious one by anyone’s standards. It’s always difficult
with populations on the margins such as IDUs – we know they’re
there, and the governments know they’re there too, but they’re
stigmatised and hidden to the general population.’
If the governments do know this is happening, is it fair to say that
there is a lack of commitment in some countries to properly address
the issue? ‘There is definitely a lack of commitment, particularly in
terms of evidence-based treatment for drug dependency,’ he says.
‘Some countries are treating them, but they might be locked into
“treatment” centres, as in the case of the Russian women who
burned to death in a centre where even the windows were barred. If
you talk to a Russian narcologist they might say “we have tens of
thousands of drug users being treated” but they’re being treated
with detox and abstinence and so on. What’s needed is evidence-
based treatment, which is primarily three things: opioid substitution
therapy, needle exchange, and – if they have HIV and need the
treatment – antiretroviral therapy.’
It can also be important to make sure people are fully aware of what
is meant by harm reduction, he maintains. ‘We need to remind people
that there are three components – five years ago anti-retroviral therapy
wasn’t considered harm reduction because almost no one was
receiving it, whether they were a drug user or not. That’s been scaled
up and now we’re saying that it’s an integral part of harm reduction.’
Given that there is clearly an urgent need for policymakers to tackle
this problem, how does the harm reduction sector go about
overcoming opposition and reluctance? ‘There are various ways to
approach it, depending on who you’re talking to,’ he says. ‘Even if they
treat drug users as a marginalised group you can make the public
health argument that says “they will get HIV and they will spread
tuberculosis, so it will come back at you.” You can’t just say that,
because we don’t inject ourselves, we’re not going to be affected by
the several million injectors who are getting infectious diseases.’
Some commentators point to a lack of joint working as another
stumbling block, with the specialist knowledge held by two distinct
groups – the drug treatment sector on the one hand and AIDS
specialists on the other – who seldom work together. ‘It’s a structural
health systems issue, where collaboration and integration is needed,’
he says. ‘We’re not talking about everyone sharing an office, but
simple things like offering a battery of tests (
eg
TB and HIV and even
hepatitis) at two different centres.’
The fact that hepatitis C can be a latent illness – with many people
having no symptoms for years – can also be a contributory factor to the
lack of data on hepatitis C prevalence in some countries. ‘There’s an
incredible gap in surveillance,’ he stresses. ‘A key finding from our
research has been how little we know about such a major epidemic,
but when we do find out what the regional situation is, it’s unbelievable.’
So what’s the answer? ‘Promoting testing is essential,’ he says. ‘The
offer of a test and linking the hepatitis tests to everything from care in
TB clinics to care in AIDS centres is a natural offer. But testing is only
the first step. Affordable, effective treatment for all in need is the goal.’
This year’s World Hepatitis Day takes place on 19 May.
The hidden timebomb
A number of today’s concurrent debates focus on HIV and
Hepatitis C infection in the injecting community.
The Daily
Update
hears from Dr Jeffrey Lazarus of theWorld Health
Organisation about how some governments are in danger
of turning a blind eye to the epidemics in their midst.
‘When we use all these buzz-
words like ‘integration’ we’re not
talking about everyone sharing an
office, but simple things like
integrating two different centres
for TB and HIV tests.’