Opioid substitution therapy in resource-poor settings.

Approximately 10% of new HIV infections worldwide are attributable to injecting drug use, often of an opiate such as heroin. 1 Opioid substitution therapy supplies illicit drug users with a replacement drug, a prescribed medicine such as methadone or buprenorphine, which is usually administered orally in a supervised clinical setting. The effectiveness of this therapy is recognized in developed countries, where the provision of opioid substitutes to opiate-dependent people is a fundamental component of the response to the dual public health problems of injecting drug use and HIV transmission. 2 However, better prevention of HIV transmission among and from injecting drug users is still needed, especially in resource-poor settings. 3 Opioid substitution therapy programmes are effective in substantially reducing illicit opiate use, HIV risk behaviours, death from overdose and criminal activity, and financial and other stresses on drug users and their families. 4–6 These programmes also improve adherence to antiretroviral therapy and the physical and mental health of injecting drug users. 4–6 Many injecting drug users who would otherwise have no contact with any health services are attracted by these programmes, which then act as gateways to other services including primary health care, HIV testing, antiretroviral therapy and services for tuberculosis , hepatitis C and sexually transmitted infections. 7 Additionally, a critical ingredient of the HIV-prevention response is mobilization of affected communities, which is only possible for injecting drug users when they are not fully occupied with obtaining an ongoing supply of illicit drugs. Despite the evidence of effectiveness, it is estimated that only 8% of injecting drug users globally currently receive opioid substitution therapy – even less in developing countries. 1 There is substantial global inequity in access – for example, 90% of injecting drug users in the United Kingdom of Great Britain and Northern Ireland and 69% in Australia are receiving such therapy; compared with 3% in China and India, and none in the Russian Federation, where opioid substitution therapy is not available. 1 Opioid substitution therapy is endorsed by the Joint United Nations Programme on HIV/AIDS, the United Nations Office on Drugs and Crime and the World Health Organization 2 – methadone and buprenorphine are on its Essential Medicines list. 8 Yet doubts about the wisdom of providing opioid substitution therapy to injecting drug users are widespread in developing countries , where abstinence is often seen as the only legitimate treatment goal, and human rights are frequently …