Health providers need to change popular opinion, that portray injecting drug users (IDUs) as already dead or less than human in order to improve access to HIV treatment.
The research suggested that health providers must focus less on the individual patient's ability to adhere to treatment, and more on conditions of health delivery that create treatment interruptions.
Among low-income and middle-income countries, almost half of all injecting drug users with HIV are in just five of these countries-China, Vietnam, Russia, Ukraine, and Malaysia.
Access to antiretroviral treatment (ART) is disproportionately low in these countries-IDUs make up two thirds of cumulative HIV cases in these countries, but only 25 percent of patients receiving ART.
Daniel Wolfe, Open Society Institute, International Harm Reduction Development Program, New York, M. Patrizia Carrieri, of INSERM, France, and Donald Shepard, a health economist at Brandeis University's Heller School for Social Policy and Management, conducted the study.
Early adherence to ART is associated with long-term virological response, with behavioural support and provision of opioid substitution treatment (OST) increasing treatment success of ART in IDUs.
Preliminary evidence suggests that increased ART provision to IDUs also reduces infectivity and HIV transmission, independent of needle sharing.
"Our analysis focused on two treatments: provision of anti-viral therapy (ART) for and provision of methadone or buphenorphine for HIV-infected drug users. We found that both are highly cost-effective. Unfortunately, many barriers limit their use," said Shepard.
Systemic barriers to ART and OST provision include stigmatisation of IDUs in health settings, medical treatment separated by specialties, bans on treatment of active IDUs, hidden or collateral fees, and multiple requirements for initiation or modification of treatment for IDUs.
Structural barriers to treatment provision result from wholesale criminalization of drug users.
Barriers include sharing the names of IDUs seeking treatment with police, arrest and harassment of IDUs in or around clinical settings, and harassment of physicians who prescribe opioids.
A necessary measure to improve ART coverage for IDUs is improved data collection, including an "equity ratio" to assess whether IDUs are receiving a fair share of antiretroviral treatment.
Other required improvements are integration of ART with OST and treatment for co-infections such as tuberculosis, and greater use of community-based treatment models and peer support.
In view of persistent human-rights violations and negative health effects of policing, detention, and incarceration, law and policy reform is needed to improve ART coverage of IDUs.
The authors say that systemic improvements "are unlikely to succeed without action to resolve the fundamental structural tension between public health approaches that treat IDUs as patients and law enforcement approaches that seek to arrest them. Police registries, arbitrary detention, and imprisonment of people who have committed no crime apart from the possession of drugs for personal use are barriers to treatment and care that cannot be overcome by counselling, electronic reminders, or peer support."
They concluded: "A basic challenge remains in the reversal of social forces, including popular opinion, that portray IDUs as already dead or less than human, and so deserving of less-than-human rights. Resurrection of IDUs from this status is beyond the healing power of ART alone, although reformation of HIV treatment systems can help to emphasise that IDUs, including those actively injecting, are capable of making positive choices to protect their health and that of their communities," adding that referral to the 1948 Universal Declaration of Human Rights could guide an approach to improve treatment for IDUs and others vulnerable to HIV infection.
The study has appeared in the Lancet series on HIV, which was presented at international AIDS conference.