Multi-Level Barriers to Effective HIV and TB Treatment for IDUs

Andrea Weddle

Twenty-five percent of IDUs reside in Eastern Europe and largely account for the rise in TB and HIV in the countries of the former Soviet Union.

There are 13 million injection
drug users (IDUs) worldwide and injection drug use remains the second
most prevalent risk factor for contracting HIV. Injection Drug
Use and Infectious Diseases

examined the comprehensive services and systems of care needed to address
the healthcare needs of this population.  

Eric Goosby, MD, emphasized
that antiretroviral treatment (ART) works with IDUs, and they should
not be denied care because of their drug use.

Goosby discussed as well the
manyl challenges in treating IDUs. Despite the evidence to the contrary,
systems of care still often treat addiction as "substance abuse"
rather than a medical disease.  In addition, they lack the continuum
of services necessary to treat it, and so the relapse rate is high.
Meanwhile, complications abound, from psychiatric illness, hepatitis
C, and renal failure to compounding conditions such as unemployment,
homelessness, and decayed family relations.  

Twenty-five percent of IDUs
reside in Eastern Europe — their sheer number posing an additional challenge — and
largely account for the rise in TB and HIV in the countries of
the former Soviet Union.  

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Daria Podekareua, PhD, presented
sobering data on both epidemics along with the intersecting barriers
to addressing IDU, TB, and HIV in this region. 250,000 Eastern Europeans
contract TB each year and in Russia alone 30,000 die annually from TB,
while another 30,000 are left disabled.  

Nonetheless, IDU-focused harm-reduction
programs are scarce due to very limited government support, with only
2% of Russian IDUs having access. Also, the decentralized health system
forces IDUs to navigate a complex system, making reliable epidemiology
studies difficult.  

Podekareua insisted an integrated
approach to addressing TB, IDU, and HIV is needed along with support
for harm reduction, improved screening, and access to prophylaxis TB
treatment improved access to ART for IDUs, as well as increased public
education.  

News Human Rights

Louisiana Is ‘Ground Zero’ for HIV, Incarceration Crises, Report Says

Kanya D’Almeida

Both of these epidemics disproportionately harm Black people, who account for 70 percent of new HIV infections in Louisiana and 66 percent of the state’s prisoners.

Thousands of prisoners in Louisiana’s county jails are routinely denied access to HIV testing and treatment, with five of the state’s 104 jails offering regular tests to inmates upon entry, according to a new Human Rights Watch (HRW) report.

The same people who are at the highest risk of HIV—people of color, sex workers, and low-income communities, for instance—face disproportionate incarceration rates in Louisiana, meaning that low-income people of color, and especially Black people, are bearing the lion’s share of the burden of inadequate HIV care in county jails, called “parish” jails in Louisiana.

Louisiana has the nation’s second highest rate of new HIV infections, and the country’s third highest rate of adults and adolescents living with AIDS, according to the report. The state has the highest incarceration rate in the nation, locking up an estimated 847 people per 100,000 residents, compared to the national average of 478 prisoners per 100,000 people. On any given day, there are roughly 30,000 people in Louisiana’s parish jails, contributing to an incarceration rate that is 150 percent of the national average.

Many of those whose treatment has been interrupted while in jail were arrested for minor, non-violent crimes, per HRW.

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Both of these epidemics disproportionately harm Black people, who account for 70 percent of new HIV infections in Louisiana (compared to 24 percent for white people), and 66 percent of the state’s prisoners—even though Black people account for 32 percent of Louisiana’s 4.6 million residents.

“This is not a coincidence,” Megan McLemore, a senior researcher at HRW and author of the report, told Rewire. “The history of the state of Louisiana has been, to say the least, disturbing in relation to African Americans.”

HRW interviewed more than 100 people for the report, from formerly incarcerated people to medical staff in parish jails to HIV service providers. What they found was a pattern of rights violations, including the failure of most parish jails to comply with recommendations by the Centers for Disease Control and Prevention that all inmates be tested for HIV upon entry at a corrections facility.

Jail officials reportedly told HRW that they avoid testing because they can’t afford to treat those who test positive: a course of medication for a single patient can fall in the range of $23,000-$50,000 per year. But the HRW report claims that failing to conduct proper testing, interrupting patients’ treatment plans, and neglecting to provide linkages to treatment centers for people leaving jails could end up costing the state much more in the long run.

Strict adherence to antiretroviral medication regimes has been found to greatly enhance successful management of HIV, the report said, by strengthening a person’s immune system and decreasing the amount of virus in the body, thereby reducing the risk of transmission. By denying inmates access to their medications, Louisiana’s parish jails are contributing to an already grave epidemic: the state is home to more than 20,272 people living with HIV, with half of them diagnosed with AIDS, according to the report.

Jail officials’ behavior heightens the stigma around HIV, advocates said. McLemore told Rewire that Louisiana’s inmate population represents some of the country’s most vulnerable and heavily policed communities.

“These are people who are already stigmatized—add HIV, and the situation becomes almost unbearable. So when jail officials intentionally avoid or neglect testing and treatment, they are not only adding to that stigma, they are actually being discriminatory,” McLemore said, adding that some caseworkers claimed their HIV-positive clients avoided disclosing their status to jail staff because they had no assurance that it would guarantee care.

Darren Stanley, a case manager at the Philadelphia Center in Shreveport, told HRW that half his clients have spent time in jail, and the majority of them are denied their medications on the inside. One of his clients, who spent three weeks in the Caddo Parish Prison in 2013, paid the ultimate price.

“I tried to get in touch with him but he was very sick without his medications,” Stanley told HRW. “He died of AIDS two weeks after he got out.”

A formerly incarcerated woman named Joyce Tosten who spoke to HRW claimed parish jail officers informed her that she would need to have her mother deliver any necessary HIV medications to the jail. But she couldn’t call her mother because she didn’t have phone privileges at the time. Other sources alleged that even when family or friends brought medications to the jail, they were never delivered.

The problem does not stop at incarceration. According to HRW, “release from parish jail is often a haphazard process consisting of whatever is left of their medication package, a list of local HIV clinics, or nothing at all.”

The report includes a series of recommendations such as setting aside adequate funding for HIV testing and care, training jail staff on effective treatment and management options, and strengthening links with local care providers and community-based centers for returning citizens.

Deon Haywood, executive director of Women With A Vision (WWAV), a New Orleans-based grassroots health collective responding to the HIV epidemic in communities of color, told Rewire that HRW’s recommendations were “spot on.”

“They speak to the conditions we have seen in the community for the past 26 years,” she said. “Through my work at WWAV and other New Orleans agencies, I’ve witnessed the failure of incarceration to better the community. We urge Louisiana to invest in education rather than criminalization, and shift the state’s resources and policies towards solutions that address the systematic inequalities that poor communities of color face on a daily basis.”

HRW’s report adds to a list of woes that Louisiana residents confront on a daily basis. The state recently ranked last on a nationwide index measuring social justice issues like poverty and racial disparities.

CORRECTION: This story has been updated to reflect Louisiana’s correct incarceration rate.

Roundups Sexual Health

This Week in Sex: News From the HIV Epidemic

Martha Kempner

This week in sex: Scientists report the first case of HIV transmission to a patient adhering to PrEP protocols, two studies show a new vaginal ring can help women prevent HIV, and young people still aren't getting tested for the virus.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

With the death of Nancy Reagan, the 1980s AIDS crisis is back in the national spotlight. But, of course, HIV and AIDS are still ongoing problems that affect millions of people. This week in sex, we review scientists reporting the first case of HIV transmission to a patient adhering to PrEP protocols, two studies showing a new vaginal ring can help women prevent HIV, and evidence that young people still aren’t getting tested for the virus.

First Case of HIV Transmission While on Truvada

Last week, Canadian scientists reported on what they believe to be the first HIV infection in a patient who was following a PreP (Pre-Exposure Prophylaxis) regimen.

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PrEP is a method of HIV prevention. By taking a daily pill that contains two HIV medicines, sold under the name Truvada, individuals who are HIV-negative but considered to be at high risk of contracting the virus can prevent infection. Studies have found that PrEP is very effective—the Centers for Disease Control and Prevention estimates that people who take the medication every day can reduce their risk of infection by more than 90 percent from sex and by more than 70 percent from injection drug use. One study of men taking PrEP found no infections over a two-and-a-half-year period.

PrEP is less effective when not taken regularly, but the new case of reported PrEP failure involves a 43-year-old man who said that he took his medication daily. His pharmacy records back up that assertion. The man’s partner has HIV, but is on a drug regimen and has an undetectable viral load. The man did report other sexual encounters without condoms with casual partners in the weeks leading up to his diagnosis.

Dr. David Knox, the lead author of this case study, notes that it is difficult to know if a patient really did adhere to the drug regimen, but the evidence in this case suggests that he did. He concluded, “Failure of PrEP in this case was likely due to the transmission of a PrEP-resistant, multi-class resistant strain of HIV 1.”

Experts say, however, that they never expected PrEP to be infallible. As Richard Harrigan of the British Columbia Center for Excellence in HIV/AIDS told Pink News, “I certainly don’t think that this is a situation which calls for panic …. It is an example that demonstrates that PrEP can sometimes be ineffective in the face of drug resistant virus, in the same way that treatment itself can sometimes be ineffective in the face of drug resistant virus.”

Still, some fear that the new study will add to the ongoing debate and apathy that seem to surround PrEP. While some experts see it as a must-have prevention tool, others worry that it will encourage men who have sex with men to forgo using condoms and perhaps increase their risk for other sexually transmitted infections. Still, only 30,000 people in the United States are taking the drug—an estimated one-twentieth of those who could benefit from it.

A New Vaginal Ring Could Help Women Prevent HIV Infection

Researchers have announced promising results from two studies looking at new technology that could help women prevent HIV. The dapivirine ring, named after the drug it contains, was developed by the International Partnership for Microbicides. It looks like the contraceptive ring, Nuvaring, and is similarly inserted high up into the vagina for a month at a time. Instead of releasing hormones to prevent ovulation, however, this ring releases an antiretroviral drug to prevent HIV from reproducing in healthy cells. (A ring that could prevent both pregnancy and HIV is being developed.)

The two studies of the ring are being conducted in Africa. One study recruited about 2,600 women in Malawi, South Africa, Uganda, and Zimbabwe. It found that the ring reduced HIV infection by 27 percent overall and 61 percent for women over age 25. The other study, which is still underway, involves just under 2,000 women in seven sites in South Africa and Uganda. Early results suggest that the ring reduced infection by 31 percent overall when compared to the placebo.

Both studies found that the ring provided little protection to women ages 18-to-21. Researchers are now working to determine how adherence and other biological factors may have impacted such an outcome.

Young People Not Getting Tested for HIV

A study in the February issue of Pediatrics found that HIV testing rates among young people have not increased in the last decade. The researchers looked at data from the Youth Risk Behavior Survey (YRBS), which asks current high school students about sexual behaviors in addition to questions about drugs and alcohol, violence, nutrition, and personal safety (such as using bike helmets and seat belts). Specifically, the YRBS asks students if they’ve ever been tested for HIV.

Using YRBS data collected between 2005 and 2013, the researchers estimated that 22 percent of teens who had ever had sex had been tested for HIV. The percent who had received HIV tests was higher (34 percent) among those who reported four or more lifetime partners. Overall, male teens (17 percent) were less likely than their female peers (27 percent) to have been tested.

Researchers also looked at data from the Behavioral Risk Factor Surveillance System, which asks similar questions to young adults ages 18 to 24. Among people in this age group, between the years of 2011 to 2013, an average of 33 percent had ever been tested. This review of data also found that the percentage of young women who get tested for HIV has been decreasing in recent years—from 42.4 percent in 2011 to 39.5 percent in 2013.

The authors simply conclude, “HIV testing programs do not appear to be successfully reaching high school students and young adults.” They go on to suggest, “Multipronged testing strategies, including provider education, system-level interventions in clinical settings, adolescent-friendly testing services, and sexual health education will likely be needed to increase testing and reduce the percentage of adolescents and young adults living with HIV infection.”

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