24 July

Needle exchanges and HIV: a mistake we can't afford to make

Successive American Presidents have listened to the evidence that needle exchanges prevent HIV infection among injecting drug users, help get people onto drug treatment programmes, save a fortune in lifetime HIV treatment costs and do not increase drug-related crime.

And each of those Presidents has concluded that it's politically too difficult to support them. Legislation bans the use of federal or local funding on needle exchanges, and yet Washington, for example, has HIV prevalence rates comparable to some African countries.

`Those hippie lefties think their going to set up a needle exchange on my patch. Good luck with that...'

Today, the conference heard from advocates for needle exchanges from the US, Moscow, China, and from Paola Barahona, from the Whitman-Walker Clinic.

The themes were the same - political indifference or hostility, lack of funds, difficult working environments and some of the most vulnerable people in their communities.

It's a very different story in England. From the early days of our HIV epidemic, the government backed and funded needle exchanges. It was brave, politically difficult, but they did it.

As a result, we have always had very low rates of HIV in injecting drug users in England, and for that, we should be proud and grateful.

Instead, changes to England's drugs policy are being considered which will see a move away from harm reduction through needle exchanges and towards abstinence-only programmes. Experts are horrified.

When study after study spells out the benefits of needle exchanges loud and clear, and people all over the world are fighting to win the right to set them up and for the funding to keep them going, how can we consider throwing away so valuable an advantage?

As Paola says of the US "Put this into the story books as an historic lesson so we can focus on strengthening these services for the future." . At the British Ambassador's reception last night, Lord Fowler talked of the importance of Britain's record on needle exchanges.

I hope those drugs policy makers in England take note. It would be all too easy to turn our success so far into a population-wide disaster.

I went to a fabulous party...

Last night, the British Ambassador to the US invited delegates from around the world to a reception at his residence in Washington. It was a lovely party – roast beef and Yorkshire pudding canapés and the kind of gin and tonic that dares you to try another one.

Annie Lennox was there, along with representatives from organisations fighting HIV from around the world.

There was a serious message, too, of commitment to tackling HIV, and pride in the part that Britain has played in this global pandemic so far.

Speeches from Lord Fowler, the British politician who has done the most to combat HIV since the epidemic began, and from Alan Duncan, Minister of State at the Department for International Development highlighted the challenge facing guests once the conference has ended.

And who knew that Alan Duncan could do such a good impression of Secretary of State for the Foreign Office, William Hague? Apparently, he says of Alan Duncan “He’s the last to know when it’s raining, and the first to know when it’s flooding.”

There are taller Ministers, granted, but that’s a little unkind!

A treatment every 2 months!!!

`A session dedicated to the recent report of the Global Commission on HIV and the Law examined the many ways in which intellectual property laws, inequality, punitive legislation in relation to the criminalization of key populations and their behaviors, as well as HIV transmission, exposure and non-disclosure are all limiting a full and effective response to the HIV epidemic.'

`The report makes clear recommendations to remove punitive laws and to strengthen and enforce protective laws which currently only pay lip service to concepts of equality.

A separate session the impact of HIV on transgendered communities raised and explored these very issues, as well as discussing the difficulties inherent in presenting a clear picture of a diverse group which is under-researched, marginalized and often completely ignored by governments and in prevention work.

Human rights violations are common and often lead to migration, which may offer the possibility of fresh start in a safer environment, but can equally make individuals even more vulnerable to homelessness, abuse and poverty.

Transgender women who do sex work are particularly vulnerable to violence by police, as they have little recourse because of criminalization in many countries and panelists within a session on criminalizing sex work called for the sponsorship of another conference specifically on this topic.

Similarly, despite theoretical legislative progress in many countries over decades, the difficulty that many women face in claiming their human rights continues to be a clear and pressing issue.

One session framed the epidemic from a woman’s viewpoint, considering and advocating for how women might become more visible and involved in addressing the structural inequalities that they face. The need for safe spaces, support to self-advocate and greater inclusion within HIV services were seen as essential in increasing visibility and challenging gender inequality.

The same rationale informed a separate session which explored the possibility of building capacity by means of women-specific community-based research which addressed the possibility of educating, consulting and prioritizing the meaningful involvement of women living with HIV. There have already been some notable successes in the area of people living with HIV-driven research and its ability to influence policy and practice, as demonstrated in projects such as the Stigma Index.

Ageing and HIV continues to be a hot topic, both in relation to the health-related issues that affect older adults and the socio-behavioral difficulties that they might face.

Research to date seems to indicate that in both these areas, older people with HIV are likely to be further disadvantaged when compared to the general population. Age-related co-morbidities seem to occur at higher rates and an earlier age than in the general population and psycho-social issues such as loneliness, isolation and financial difficulties are likely to be more acute for many people living with HIV.

The difficulty of dealing with multiple chronic conditions is seen as a particular concern, both in terms of clinical management within multidisciplinary teams as well as issues of poly-pharmacy, highlighting a need not only for further research in this field, but for personalization of both medicine and medical care to suit individuals in all health settings.

While today’s society considers ‘older adults’ to be in their late 60’s and above, the research being done within the HIV-positive population is looking at issues for those over 50. It may be necessary to consider parallel standards of care and recommendations for testing and monitoring which address their needs at an earlier age than their HIV-negative counterparts. In the arena of social care, social groups and peer support services are now being planned in the hope of alleviating issues of isolation and depression, which while common in older adults are likely to be compounded by issues of anxiety around HIV stigma and discrimination in the HIV-positive population.

Finally, while there is a distinct shortage of presentations on medical research and clinical studies at this particular conference, an overview of the 25 years of HIV medication highlighted the astonishing improvements in lfe expectancy, ease-to-take regimens and tolerability.

It went on to describe several new ARV therapies in current clinical trials. Integrase inhibitors elvitegravir and dolutegravir are the closest to approval, with new NRTIs, a CCR% antagonist and a CD4 attachment inhibitor following in phase 1 and 2 trials.

Cobicistat is a booster drug rather than an anti-HIV medication, but new data shows an improved lipid profile in comparison to current PI booster ritonavir. Similarly, switching from a boosted PI and truvada to the latest one-pill combo of rilpivirine/truvada showed a marked reduction in lipids and improvements in long-term cardiovascular risk.

 More one-pill formulations are on the way, with a further four in current trials including the quad pill (which uses cobicistat as a booster), as well as the first combination to co-formulate kivexa with another drug rather than truvada - in this case, with dolutegravir.

Recently published research showed the combination to be more effective than atripla and with fewer side effects. Moving on from one a day, the prospect of longer-acting medications is showing promise, with rilpivirine and another new drug pushing dosing intervals to between 26-55 days!

However, it should be noted that this option is more likely to be via an injection than in tablet form.'

Garry Brough
Policy & Public affairs
Membership Officer 

It's a protest. Brazilian-style.