Time to act: Fast -Tracking the response for people who inject drugs in Asia and the Pacific

Commentary Asia and the Pacific region is one of the world’s most vibrant places in terms of economic growth and social advancement. It captures many superlatives: the planet’s highest proportion of young people, the largest megacities in the world and Asia wins the crown of "global growth leader" again and again. However, despite the dynamism, some citizens are falling through the cracks. This is particularly true for people who inject drugs (PWID). With 3.15 million PWID, in terms of sheer numbers, East Asia and Southeast Asia has the largest injecting drug problem in the world and is home to one in four PWID globally [1]. People who inject drugs have multiple vulnerabilities—to HIV, hepatitis, tuberculosis and other infectious diseases; they account for an estimated 30 % of new HIV infections outside sub-Saharan Africa. About a third of PWID are living with HIV in Southwest Asia [1], and a number of countries have reported HIV prevalence higher than 10 % [2]. National figures often do not tell the full story, with some localities reporting significantly higher prevalence. In Cebu City, Philippines, HIV prevalence among PWID was estimated at 52.3 % in 2013 [3], and in Faisalabad, Pakistan, it was as high as 52.5 % in 2011 [4]. Scientific evidence shows that to respond to HIV and other health risks of people who inject drugs, it is important to develop programmes which cater to their needs. The Joint United Nations Programme on HIV/ AIDS (UNAIDS), the United Nations Office on Drugs and Crime (UNODC) and the World Health Organization (WHO) have recommended a package of nine interventions, commonly referred to as the comprehensive approach to injecting drug use [5]. The first four interventions—needle-syringe programmes (NSP), opioid substitution therapy (OST), HIV testing and counselling and the provision of antiretroviral therapy (ART)—are critical for effective national programmes. There is compelling evidence that NSP and OST are effective in reducing the sharing of injecting equipment and averting HIV infections. In combination with ART, these interventions diminish HIV transmission, decrease mortality, reduce drug dependency and improve quality of life. Several countries in the region have taken these recommendations to heart and implemented parts of the comprehensive harm reduction package. In the late 1990s, China had a fast-growing HIV epidemic among people who inject drugs and its health authorities began introducing OST sites and needle-syringe programmes. By the end of 2014, more than 700 OST sites were operating in China. HIV incidence rate dropped by 87.6 % from 0.95 % in 2006 to 0.12 % in 2014 among those registered in the clinics [6]. Recently, India and Myanmar have also increased their OST coverage. Despite these pockets of success, the coverage of harm reduction programmes remains inadequate in Asia and the Pacific region. High coverage of needle-syringe programmes is defined by WHO, UNAIDS and UNODC as more than 200 needles or syringes provided per PWID a year. Only four countries reported reaching high coverage in 2014, and five reported that less than 50 % of PWID used clean equipment for their last injection [2]. PWID frequently face stigma and discrimination when seeking health services and are far less likely to receive ART than others living with HIV due to social marginalization and the flawed perception that they are unable to adhere to treatment effectively. While current national monitoring systems are not designed to capture data on access to ART for PWID, a recent review suggests that less than five PWID received ART per 100 HIV-positive PWID [7]. Not only is coverage low, but there are worrying signs that some countries with a high HIV burden among PWID are scaling down harm reduction interventions [8]. This is undoubtedly due to the phasing out of support by international donors with little new funds * Correspondence: [email protected] UNAIDS Regional Support Team for Asia and the Pacific, United Nations Building, Rajadamnern Nok Avenue, Bangkok 10200, Thailand Full list of author information is available at the end of the article