Print version ISSN 0042-9686
Bull World Health Organ vol.90 n.3 Genebra Mar. 2012
Zunyou WuI,*; Nicolas ClarkII
INational Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing, 102206, China
IIManagement of Substance Abuse, World Health Organization, Geneva, Switzerland
An estimated 11 million people are dependent on heroin or other opioid drugs, a condition associated with a high morbidity and 15-fold mortality from causes including overdose and infections such as human immunodeficiency virus (HIV), tuberculosis (TB) and hepatitis.1 Approximately 10% of HIV infections worldwide are thought to be due to injecting drug use,2 and approximately 230 million people worldwide are estimated to have chronic hepatitis C.3 Compliance with treatment for HIV and TB is difficult to achieve in this group, and contributes to the spread of drug resistance, including multi-drug resistant TB. Where it has been measured, the social cost of illicit drug use has been found to rival that of tobacco and alcohol, due to a combination of health care costs, lost productivity and crime.4
Recent World Health Organization guidelines have endorsed methadone maintenance treatment as the mainstay of opioid dependence treatment.1 It has been shown to reduce premature mortality by two thirds and opioid overdose mortality tenfold. Further, it dramatically reduces illicit opioid use, crime and HIV spread, and improves adherence to HIV, TB and hepatitis treatment. Since the first studies of methadone treatment were published in the 1960s, methadone has been used extensively for the treatment of opioid dependence and has saved millions of lives worldwide.
Despite the high need for treatment, global coverage of methadone and other services for people with opioid dependence is poor, with most treatment limited to high-income countries.5 Many countries have started pilot and small-scale programmes, which have demonstrated similar effectiveness to those in high-income settings.6 However, only a few low- and middle-income countries have managed to rapidly increase the number of people receiving treatment for opioid dependence and other harm reduction measures to prevent the spread of HIV, TB and viral hepatitis. China is one example, as rapid expansion of methadone maintenance treatment programmes (initiated in 2004, and now covering more than 300 000 opiate users) has made remarkable improvements in the quality of life of drug users and their families and in reducing HIV spread in this population.7, 8 The Islamic Republic of Iran is another country that has rapidly increased its treatment of opioid dependence.9 Unfortunately however, this affordable and effective treatment for opioid dependence remains unavailable in most other low- and middle-income countries, as they still face many challenges in expanding methadone maintenance treatment programmes.10 As a result, both drug use and drug-related HIV epidemics are continuing to have devastating effects in these countries.2, 10, 11
The purpose of this theme issue of the Bulletin is to highlight the paths to success that some countries have achieved, so that others may consider similar solutions. This purpose will be achieved via the following three allied objectives.
The first objective is to describe the global situation with regard to opioid dependence and its relationship to HIV and TB, highlighting the current data on the global response to these problems and examining what has enabled some countries to scale up rapidly to address the joint problems of opioid dependence, HIV and, in many cases, TB. It is expected that a series of papers from different countries and geographical regions, examining the process of scaling-up, its challenges and responses to those challenges, will be included. These articles will describe policies and strategies used for scaling-up national methadone maintenance treatment programmes, methods of evaluating treatment success, and means of addressing common co-morbidities such as HIV, TB and hepatitis.
The second objective is to facilitate communication and collaboration within the scientific, medical and public health communities across political borders so that low- and middle-income countries in all regions, can learn from their neighbours the best practices in providing safe and effective treatment of opioid dependence and related conditions. As the Bulletin is free to developing countries, it is an ideal platform in which to share the experiences of other low- and middle-income countries.
The third objective is to disseminate key findings to high-level decision-makers in an attempt to promote a stronger commitment to a therapeutic approach to opioid-dependence treatment and its wider application in contributing to the reduction of new HIV infections, particularly among injecting drug users. The United Nations Millennium Development Goals urge us to "have halted by 2015 and begun to reverse the spread of HIV/AIDS" and the Joint United Nations Programme on HIV/AIDS has stated that "to get to zero new infections by 2015, all new HIV infections [must be] prevented among people who use drugs". Although the epidemic appears to have stabilized in most regions, with the number of new HIV infections declining 19% globally over the past decade, HIV infection rates are increasing in several countries in eastern Europe and central Asia. These countries have expanding, concentrated epidemics, notably among people who inject drugs and their sexual partners.
The deadline for submissions to this theme issue is 31 May 2012. Manuscripts should follow the Bulletin's guidelines for contributors, specify this call for papers in the covering letter and be submitted via http://submit.bwho.org
1. Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence. Geneva: World Health Organization; 2009. [ Links ]
2. Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA et al.; 2007 Reference Group to the UN on HIV and Injecting Drug Use. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet 2008;372:1733-45. doi:10.1016/ S0140-6736(08)61311-2 PMID:18817968 [ Links ]
3. Nelson PK, Mathers BM, Cowie B, Hagan H, Des Jarlais D, Horyniak D et al. Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: results of systematic reviews. Lancet 2011;378:571-83. doi:10.1016/ S0140-6736(11)61097-0 PMID:21802134 [ Links ]
4. International guidelines for estimating the costs of substance abuse (2nd edition). Geneva: World Health Organization; 2003. [ Links ]
5. Mathers BM, Degenhardt L, Ali H, Wiessing L, Hickman M, Mattick RP et al.; 2009 Reference Group to the UN on HIV and Injecting Drug Use. HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage. Lancet 2010;375:1014-28. doi:10.1016/S0140-6736(10)60232-2 PMID:20189638 [ Links ]
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7. Sullivan SG, Wu Z. Rapid scale up of harm reduction in China. Int J Drug Policy 2007;18:118-28. doi:10.1016/j.drugpo.2006.11.014 PMID:17689354 [ Links ]
8. Yin W, Hao Y, Sun X, Gong X, Li F, Li J et al. Scaling up the national methadone maintenance treatment program in China: achievements and challenges. Int J Epidemiol 2010;39(Suppl 2):ii29-37. doi:10.1093/ije/dyq210 PMID:21113034 [ Links ]
9. Farnia M, Ebrahimi B, Shams A, Zamani S. Scaling up methadone maintenance treatment for opioid-dependent prisoners in Iran. Int J Drug Policy 2010;21:422-4. doi:10.1016/j.drugpo.2010.03.008 PMID:20413287 [ Links ]
10. Mesquita F, Jacka D, Ricard D, Shaw G, Tieru H, Hu Y et al. Accelerating harm reduction interventions to confront the HIV epidemic in the Western Pacific and Asia: the role of WHO (WPRO). Harm Reduct J 2008;5:26. doi:10.1186/1477-7517-5-26 PMID:18680604 [ Links ]
11. Achmad YM, Istiqomah AN, Iskandar S, Wisaksana R, van Crevel R, Hidayat T. Integration of methadone maintenance treatment and HIV care for injecting drug users: a cohort study in Bandung, Indonesia. Acta Med Indones 2009;41(Suppl 1):23-7. PMID:19920294 [ Links ]