HIV pre-exposure prophylaxis in injecting drug users.

2060 www.thelancet.com Vol 381 June 15, 2013 Globally, there are an estimated 15·9 million injecting drug users, 3 million of whom have HIV. The illicit nature of injection drug use and associated social stigma have created substantial challenges for HIV prevention in this group. Despite these obstacles, several programmes have shown that HIV transmission in injecting drug users can be prevented, stabilised, and even reversed with needle exchange programmes. However, the HIV epidemic continues to grow in this high-risk population in some regions, particularly in eastern Europe, central Asia, and, since 2007, sub-Saharan Africa. Much more needs to be done to reduce the continuing high rates of HIV transmission in injecting drug users. Findings from a series of randomised placebocontrolled trials, viewed cumulatively, provide compelling evidence (fi gure) that antiretrovi ral pre-exposure prophyl axis (PrEP), when taken, is eff ective in preventing mother-to-child transmission of HIV, sexual transmission in men who have sex with men, and sexual transmission between men and women. In women, both oral and topical antiretrovirals have been shown to prevent sexual transmission. However, there is no rigorous evidence on whether PrEP is eff ective in preventing parenteral HIV transmission. In 2005, the US Centers for Disease Control and Prevention initiated the Bangkok Tenofovir Study to address this major gap and assess the effi cacy of daily oral tenofovir disoproxyl fumarate (tenofovir) in preventing parenteral transmission of HIV. In The Lancet, Kachit Choopanya and colleagues report the results of this important study. They enrolled 2413 participants who reported injecting drugs within the previous 12 months and followed them up for a mean of 4·0 years. During follow-up, 50 participants acquired HIV: 17 were in the tenofovir group (HIV incidence=0·35 per 100 person-years) and 33 were in the placebo group (0·68 per 100 person-years), which translates into 49% eff ectiveness of tenofovir (95% CI 9·6–72·2). Additional per-protocol and drug level analyses drew attention to the importance of adherence to achieve high levels of protection from PrEP. Although fi ndings from this study provide the evidence to show that PrEP is eff ective in preventing HIV infection in people who inject drugs, it is less clear as to whether the fi ndings show that PrEP prevents parenteral HIV pre-exposure prophylaxis in injecting drug users Nonetheless, there are signs that Muslim majority coun tries including those in the Middle East are beginning to address the HIV epidemic; many countries have recently developed national plans on HIV. Parts of the Islamic world are also in the process of profound sociocultural transitions that are leading to increased tolerance and acceptance of practices such as premarital and extramarital sex. What is often forgotten in the Islamic world’s response to the HIV epidemic is that central in the teachings of Islam is the concept of compassion and justice. Muslims are encouraged to recite the phrase Bismillah ir-rahman ir-rahim, “In the name of Allah, most benefi cent, most merciful”, before undertaking any action—large or small.