Burden of of illicit drug use and benefits of early ART

Illicit drug use and HIV

Adeeba Kamarulzaman from Malaysia presented on HIV in people who inject drugs (PWID). Due to time constrains, PrEP and HCV co-infection was not discussed. Abstract#20

Overall illicit drug use causes 1% of global disease burden and is the 8th largest contributor to years lost to disability among males. In countries where HIV incidence is increasing, 70-80% of HIV cases are among PWID.

Effective strategies such as needle exchange programs and opiate substitution therapy have been shown to be effective in several countries. However, worldwide there is poor overall implementation of such programs. Globally for every 100 PWID only 8 are on opiate substitution therapy, and only 2 needles per PWID per month exchanged.

There are unmet needs amongst further marginalised groups - notably women, adolescents and men who have sex with men (MSM) drug users.

Prisons are a high risk environment for the ongoing transmission of HIV and other infectious diseases such as TB. Prisons do present an opportunity to treat, and when treated, AIDS related mortality reaches parity with the general population. However, this effect is not sustained once prisoners are released, as continuity of care cannot be guaranteed.

Treatment can be used as prevention in high income countries - as shown by studies in Vancouver and Baltimore. This is more difficult in lower income countries, where active drug injection, incarceration and lack of an HIV care provider result in poorer adherence to ART and poorer HIV suppression.

Addressing the stigma of addiction and HIV among PWID will not only have benefits for individuals, but lower the overall burden of disease for a country, leading to positive economic outcomes.

Effect of ART early in HIV infection

Increasingly the role of ART initiation at or soon after primary infection is gaining significance. Not only does early ART result in a higher chance of post-treatment control, but preservation of the immune system is seen, with more chance of a higher CD4 level and CD4/CD8 ratio ≥1. Correspondingly, there is a lower HIV reservoir established, with the potential for "functional cure".

Early HIV control is important because many of the long-term effects of chronic HIV infection and ART are related to chronic immune activation for example, diverse conditions such as cardiovascular disease, neurocognitive effects and various cancers.