HIV and People Who Inject Drugs

"Data for the year 2020 should be interpreted with caution due to the impact of the COVID-19 pandemic on access to HIV testing, care-related services, and case surveillance activities in state/local jurisdictions. The overall number of HIV diagnoses in the United States in 2020 (30,335) was 17% lower than in 2019 (Figure A). The decline in 2020 was larger than the average yearly decline (2%–3%) observed during 2017–2019. The underdiagnosis of HIV in 2020 was due to disruptions in clinical care services, patient hesitancy in accessing clinical services, and shortages in HIV testing reagents/materials [4–8]. To emphasize the need for caution, tables presenting data for the year 2020 include “COVID-19 pandemic” in the title, and the 2020 column is highlighted in tables that provide multiple years of data.

"During 2021, the overall number of HIV diagnoses in the United States (35,769) partially rebounded and was 18% higher than in 2020 (Figure A). The partial rebound in the number of HIV diagnoses may be due to the identification and reporting of HIV diagnoses missed in 2020. The ongoing impact of the pandemic on HIV testing, diagnoses, and treatment has varied by jurisdiction, with some recovering more slowly than others. In 2021, some jurisdiction’s levels of HIV testing, diagnoses, and treatment remained below pre-COVID-19 levels [9]. Increasing testing efforts and innovative strategies to reach persons with undiagnosed HIV infection are needed to offset this diagnosis gap. Death data for years 2020 and 2021 should be interpreted with caution due to excess deaths in the United States population attributed to the COVID-19 pandemic. For additional information, see https://www.cdc.gov/nchs/nvss…. Assessments of trends in HIV diagnoses, deaths, and prevalence that include data for the year 2020 should be interpreted with caution."

"At year-end 2021 in the United States and 6 dependent areas, 116,350 PWID were living with diagnosed HIV infection. Prevalence by race/ethnicity was as follows (Table 16b):

"• American Indian/Alaska Native—495 (< 1%)
"• Asian—663 (< 1%)
"• Black/African American—51,368 (44%)
"• Hispanic/Latino—31,657 (27%)
"• Native Hawaiian/other Pacific Islander—51 (< 1%)
"• White—26,233 (23%)
"• Multiracial—5,748 (5%)"

"In the United States, 10% of HIV infections diagnosed in 2018 were attributed to unsafe injection drug use or male-tomale sexual contact among persons who inject drugs (PWID) (1). In 2017, among PWID or men who have sex with men and who inject drugs (MSM-ID), 76% of those who received a diagnosis of HIV infection lived in urban areas* (2). To monitor the prevalence of HIV infection and associated behaviors among persons who reported injecting drugs in the past 12 months, including MSM-ID, CDC’s National HIV Behavioral Surveillance (NHBS) conducts interviews and HIV testing among populations of persons at high risk for HIV infection (MSM, PWID, and heterosexually active adults at increased risk for HIV infection) in selected metropolitan statistical areas (MSAs) (3). The estimated HIV infection prevalence among PWID in 23 MSAs surveyed in 2018 was 7%. Among HIV-negative PWID, an estimated 26% receptively shared syringes and 68% had condomless vaginal sex during the preceding 12 months. During the same period, 57% had been tested for HIV infection, and 55% received syringes from a syringe services program (SSP). While overall SSP use did not significantly change since 2015, a substantial decrease in SSP use occurred among Black PWID, and HIV prevalence among Black PWID was higher than that among Hispanic and White PWID. These findings underscore the importance of continuing and expanding HIV prevention programs and community-based strategies for PWID, such as those provided by SSPs, especially following service disruptions created by the COVID-19 pandemic (4). Efforts are needed to ensure that PWID have low-barrier access to comprehensive and integrated needs-based SSPs (where legally permissible) that include provision of sterile syringes and safe syringe disposal, HIV and hepatitis C virus (HCV) testing and referrals to HIV and HCV treatment, HIV pre-exposure prophylaxis, and treatment for substance use and mental health disorders."

"In 2021, compared with 2017, the annual number and rate of persons living with diagnosed HIV infection increased in the United States and 6 dependent areas, (Table 15b). At year-end 2021, 1,088,769 persons were living with diagnosed HIV infection (persons aged ≥ 13 years: 1,087,503) (Tables 15b and 17b). The overall rate of persons living with diagnosed HIV infection was 324.5 (persons aged ≥ 13 years: 383.7) (Figure 10, Table 15b)."

"From 2015 to 2018, HIV prevalence among PWID [People Who Inject Drugs] in selected MSAs [Metropolitan Statistical Areas] was unchanged at 7%. This analysis found a higher HIV prevalence among Black PWID than among Hispanic or White PWID, despite fewer reported risk behaviors associated with HIV infection among Black PWID. In 2018, when compared with Hispanic or White PWID, fewer Black PWID shared syringes or injection equipment and had condomless anal sex. Overall, SSP use did not significantly increase since 2015 (from 52% to 55%), but a substantial decrease in SSP use among Black PWID (from 51% to 40%), and significantly lower use of SSPs in 2018 among Black PWID compared with Hispanic and White PWID was observed. Lower SSP use among Black PWID in the context of disproportionally higher rates of HIV diagnoses in Black communities (1) might lead to increased risk for HIV transmission among Black PWID. It is critical to explore and address the causes for these disparities in SSP use and HIV infection rates.

"In 2020, the COVID-19 pandemic impeded delivery of prevention services for PWID nationally, resulting in a substantial reduction in SSP operations and provision of medication for opioid use disorder (4). This analysis highlights the ongoing need for risk reduction and improved access to HIV prevention services among PWID than existed before the COVID-19 pandemic, especially because access to these services was reduced as a result of the pandemic. Findings from this analysis and continuous monitoring of characteristics and risk behaviors associated with HIV infection of PWID will facilitate estimation of how the pandemic disrupted behaviors as well as access to essential prevention services among PWID."

"• Gender: From 2014 through 2018 in the United States and 6 dependent areas, the largest percentage increase (24%) in the number of persons living with diagnosed HIV infection was among transgender MTF (Table 14b). At year-end 2018, the largest percentage (75%) of persons living with diagnosed HIV infection were male, followed by females (24%) (Table 14b). Transgender MTF, transgender FTM, and AGI each accounted for less than 1%.

"• Age group: From 2014 through 2018 in the United States and 6 dependent areas, the largest percentage increase (51%) in the rate of persons living with diagnosed HIV infection was among persons aged 65 years and older (from 130.0 in 2014 to 196.6 in 2018) (Table 14b). At year-end 2018, persons aged 50–54 years made up the largest percentage (15%) of persons living with diagnosed HIV (Table 14b). The highest rate (762.6) was among persons aged 50–54 years, followed by those aged 55–59 years (704.3), and those aged 45–49 years (600.0).

"• Race/ethnicity: At year-end 2018 in the United States, the highest rate (1,034.2) and the largest percentage (41%) were those for blacks/African Americans (Table 14a). Among the remaining race/ethnicity groups, the rates were 665.7 for persons of multiple races, 386.4 for Hispanics/Latinos, 154.0 for whites, 150.3 for Native Hawaiians/other Pacific Islanders, 129.6 for American Indians/Alaska Natives, and 80.9 for Asians.

"At the end of 2018, 1,040,352 adults and adolescents were living with diagnosed HIV infection in the United States and 6 dependent areas (Figure 10). Among 795,198 males living with diagnosed HIV infection, 35% were black/African American, 33% were white, 25% were Hispanic/Latino, 5% were males of multiple races, and 2% were Asian. Less than 1% each were American Indian/Alaska Native and Native Hawaiian/other Pacific Islander. Among 245,154 females living with diagnosed HIV infection, 58% were black/African American, 20% were Hispanic/Latino, 16% were white, 5% were females of multiple races, and 1% were Asian. Less than 1% each were American Indian/Alaska Native and Native Hawaiian/other Pacific Islander."

"Region and race/ethnicity: In 2018 in the United States and 6 dependent areas, 2,492 diagnosed HIV infections were among PWID. Of these, the largest number of HIV infection diagnoses were in the South (976), followed by the Northeast (595) (Figure 19). In all regions, the largest percentage of diagnosed HIV infections among PWID was among whites. In the South, whites accounted for 436 diagnosed HIV infections among PWID (45%), blacks/African Americans accounted for 359 (37%), and Hispanics/Latinos accounted for 143 (15%) (Table 6b). In the Northeast, whites accounted for 212 diagnosed HIV infections among PWID (36%), blacks/African Americans accounted for 206 (35%), and Hispanics/Latinos accounted for 152 (26%). Please use caution when interpreting data for American Indian/Alaska Native, Asian, and Native Hawaiian/other Pacific Islander PWID, and persons of multiple races who inject drugs: the numbers are small."

"The first cases of Pneumocystis carinii(jirovecii) pneumonia among young men, which were subsequently linked to HIV infection, were reported in the MMWR on June 5, 1981 (1). At year-end 2019, an estimated 1.2 million persons in the United States were living with HIV infection (2)."

"This report describes data from 11,437 PWID who participated in NHBS in 2018, of whom 69% identified as male, 30% female, and 1% transgender; 39% were white, 33% were black, and 21% were Hispanic or Latino; 36% were aged ≥50 years (Table 1). Among all participants, 26% had no health insurance, 21% had not visited a health care provider, and the household income of 75% of participants was at or below the federal poverty level.

"In 2018, 6% of participants with a valid NHBS HIV test result tested positive for HIV (Table 2). By gender, HIV prevalence was as follows: 6% among males, 6% among females, and 28% among transgender. By race and ethnicity, HIV prevalence was as follows: 9% among blacks, 8% among Hispanics or Latinos, and 4% among whites.

"CDC recommends that persons at increased risk of HIV infection, including PWID, undergo HIV testing at least annually [10]. Among participants who did not report a previous HIV-positive test result or who had received their first HIV-positive test result less than 12 months before the interview, 55% reported that they had been tested for HIV in the 12 months before the interview, and 90% reported that they had ever been tested (Table 3).

"Among participants who reported being tested for HIV in the 12 months before the interview, 66% reported their most recent test was performed in a clinical setting while 29% reported being tested in a nonclinical setting, such as an HIV counseling and testing site, an HIV street outreach program or mobile unit, a SSP, or at home (Table 4)."

"Effective treatment has increased life expectancy after HIV infection, and deaths from non-AIDS-related causes now exceed deaths from AIDS for those with HIV in the US [35]. Medical costs of treating HIV-infected individuals as they age now include costs of both HIV-related and HIV-unrelated medical care. We estimated the medical cost saved by averting one HIV infection in the United States, taking into account the costs that would have been incurred by similar at-risk individuals in the absence of HIV infection. We project discounted medical cost savings of $229,800 by permanently averting one HIV infection based on current care patterns in the US and $49,500 if one HIV infection is delayed by 5 years. Our analysis shows that as HIV care becomes more effective, the cost avoided by averting one HIV infection also increases. Improved care is cost-effective by accepted standards in the US, it is not cost-saving [36]. The added years of life, however, result in additional costs for treatment that would not have occurred in the absence of an infection.

"Our projections of lifetime medical costs for HIV-infected individuals of $326,500 in the base case and $435,200 in the optimal care case are comparable to recent model-based estimates of lifetime costs for individuals in the US entering care with CD4 201–350/μl ($332,300 in 2012 US dollars) and >500/μl ($443,000) respectively [37], and costs from entry into care (not shown) are consistent with previous estimates of these costs in France using the CEPAC model [38]. Our projection of medical cost savings of $229,800 is substantially lower than the previous estimate of $303,100 in 2004 US dollars ($361,400 in 2012 US dollars) [7] for several reasons. First, we now account for medical costs that would have been incurred in the absence of an HIV infection. Second, our previous analysis did not adjust mortality for risk group characteristics that lower average life expectancy [23], thereby reducing costs, nor did they adjust costs for health service utilization by different risk groups. Our life expectancy estimates are lower than two other recent model-based analyses in the United States and the United Kingdom [37, 39], likely reflecting the race/ethnicity and risk-category mortality effects in our model. Our results are consistent with these models, however, in projecting substantial life expectancy losses associated both with becoming HIV infected and with delayed initiation of treatment after infection.

"Consistent with other analyses [7, 37], we found that ART medications represent the largest component of cost for HIV-infected individuals. We found that non-HIV chronic care medications represent a substantial component of cost as well, emphasizing the significant cost of managing non-HIV comorbidities in an aging HIV-infected population [13, 40]. These comorbidities are frequently managed by HIV primary care providers [41]. Our results are somewhat sensitive to assumptions about future use of generic HIV drugs in the US. This points to the potential importance of future availability of generic drugs in lowering the cost of HIV care, depending on regimens selected and adherence [32].

"Our analysis also indicates that the value of HIV primary prevention may be greater when the effects of preventing secondary transmission to HIV-uninfected partners are taken into account, which would increase the value of interventions targeting individuals at high risk of transmitting to multiple partners. The magnitude of this impact is greater the longer individuals remain uninfected after avoiding a secondary transmission. The current relatively stable HIV incidence trends in the US [15] suggest these uninfected partners are at high risk for eventual HIV infection. If the probabilities of secondary transmission we used already take into account this additional risk, the value of primary prevention would be even higher."

Editor's Note: This article has the following correction:

"In the December 1, 2019 Supplement 2 of JAIDS Journal of Acquired Immune Deficiency Syndromes, in the article titled 'Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia', the authors mistakenly reported the estimated cost savings for Baltimore to be $62.4 million annually and $624 million over 10 years, and the 1-year return on investment (ROI) factoring in the cost of syringe exchange programs to be $46.8 million. The correct cost savings estimates are $43.4 million annually and $434.3 million over 10 years, and the correct 1-year ROI estimate is $32 million."

Following is the original, uncorrected quote:

"Our findings also demonstrate that averted HIV diagnoses translated to cost savings for cities where most PLWH are recipients of publicly funded healthcare. The forecasts estimated an average of 1059 HIV diagnoses in Philadelphia and 189 HIV diagnoses in Baltimore averted annually. Multiplying the lifetime costs of HIV treatment per person ($229,800)²⁵ by the average number of diagnoses averted annually in both cities yields an estimated annual saving of $243.4 million for Philadelphia and $62.4 million for Baltimore. Considering diagnoses averted over the 10-year modeled period, the lifetime cost savings associated with averted HIV diagnoses stemming from policy change to support SEPs may be more than $2.4 billion and $624 million dollars for Philadelphia and Baltimore, respectively. Because SEPs are relatively inexpensive to operate,²⁶ overall cost savings are substantial even when deducting program operational costs from the total amount. Considering annual program expense ($390,000 in 2011 for Philadelphia²⁷ and $800,000 estimated in FY 2017 for Baltimore²⁸) (Kathleen Goodwin, Baltimore City Health Department, personal communication, January 3, 2017) and cost savings in each city, and a conservative estimate that 75% of these savings would be experienced in the public sector, the 1-year return on investment in SEPs remains in the hundreds of millions of dollars ($182.5 M for Philadelphia, $46.8 M for Baltimore). Small investments in SEPs may yield large savings in HIV treatment costs, so implementing SEPs may liberate resources for other important interventions, such as expanded access to medication-assisted treatment, overdose prevention, and housing.

"Another implication pertains to how variations in SEP implementation may have influenced intervention effectiveness. Policies governing SEPs affect not only the overall number of syringes distributed annually but also the ability of PWID to obtain sufficient coverage for all injection events. For example, PPP's clients may exchange syringes for themselves and others; recent data show that the mean number of syringes exchanged per exchange event increased from 1.53 in 1999 to 1.82 in 2014.¹³ In addition, PPP's annual syringe distribution has consistently increased from approximately 811,000 in 1999 to 1.2 million in 2014,¹³ allowing for greater coverage of injection events and more opportunities for disease prevention.

"By contrast, Baltimore's SEP had a one-for-one (1:1) exchange policy from 1994 to 1999 but, in 2000, switched to a more restrictive policy, where clients were allowed 1:1 exchange for program-distributed syringes but could receive 1 sterile syringe in exchange for 2 nonprogram syringes. From 2005 to 2014, the SEP returned to the less restrictive 1:1 policy, after which they shifted to a need-based distribution model whereby PWID could access as many syringes as needed. Baltimore City's health commissioner estimated that moving from the 1:1 to the needs-based distribution policy could increase coverage of injection events from 42% to 61%.²⁹ More flexible approaches to syringe access in Baltimore could have resulted in greater injection coverage and more dramatic declines in IDU-associated HIV diagnoses earlier. Regulations limiting clean needle and syringe distribution are important operational issues to consider if policy changes supporting harm reduction for PWID are to have optimal impact."

"In 2021, the world set ambitious law reform targets to remove criminal laws that are undermining the HIV response and leaving key populations behind. Recognising decriminalization as a critical element in the response, countries made a commitment that by 2025 less than 10% of countries would have punitive legal and policy environments that affect the HIV response. The Global AIDS Strategy set as a target that less than 10% of countries would criminalise sex work, possession of small amounts of drugs, same-sex sexual activity, and HIV exposure, non-disclosure and transmission."

"Methods

"The research literature on the effectiveness of syringe services programs in controlling HIV transmission among persons who inject drugs and guidelines for syringe services program that are 'functioning very well' were used to estimate the cost-saving threshold at which a syringe services program becomes cost-saving through preventing HIV infections versus lifetime treatment of HIV. Three steps are involved: (1) determining if HIV transmission in the local persons who inject drugs (PWID) population is being controlled, (2) determining if the local syringe services program is functioning very well, and then (3) dividing the annual budget of the syringe services program by the lifetime cost of treating a single HIV infection.

"Results

"A syringe services program in an area with controlled HIV transmission (with HIV incidence of 1/100 person-years or less), functioning very well (with high syringe coverage, linkages to other services, and monitoring the local drug use situation), and an annual budget of $500,000 would need to prevent only 3 new HIV infections per year to be cost-saving.

"Conclusions

"Given the high costs of treating HIV infections, syringe services programs that are operating according to very good practices ('functioning very well') and in communities in which HIV transmission is being controlled among persons who inject drugs, will almost certainly be cost-saving to society."

"Syringe services programs are harm reduction programs that provide a wide range of services including, but not typically limited to, the provision of new, unused hypodermic needles and syringes and other injection drug use supplies, such as cookers, tourniquets, alcohol wipes, and sharps waste disposal containers, to PWID. Comprehensive SSPs also either directly provide, or offer linkage or referrals to entities that provide: substance use disorder treatment, including medication for addiction treatment; vaccination for viral hepatitis; screening for viral hepatitis, HIV, sexually transmitted infections, tuberculosis, and other infectious diseases; provision of pre- and post-exposure prophylaxis for HIV; naloxone and other overdose prevention tools; peer support services; educational materials and training in areas related to injection drug use; and referral and linkage to other services, including medical care, mental health services, and other support services.¹⁶ Contrary to popular perception, SSPs do not increase crime in areas where programs are based and do not increase illegal drug use.¹⁷ Further, “Nearly 30 years of research has shown that comprehensive SSPs are safe, effective, and cost-saving … and play an important role in reducing the transmission of viral hepatitis, HIV, and other infections.”¹⁸ Additionally, PWID who participate in an SSP are “five times more likely to enter drug treatment and about three times more likely to stop using drugs than those who don’t use the programs.”¹⁹ Individuals who regularly use an SSP are also “nearly three times as likely to report a reduction in injection frequency as those who have never used an SSP.” SSPs are also an important tool in the fight against unintentional drug overdose by teaching PWID how to recognize and respond to a drug overdose, as well as by providing participants with naloxone and training on administration.²¹

"Although only 38 states, the District of Columbia, and Puerto Rico either explicitly or implicitly authorize SSPs through statute, regulation, or executive order, as of September 2021, there are 392 operational SSPs in 44 states, the District of Columbia, and Puerto Rico.^22,23

"Sex (at birth) and transmission category: From 2014 through 2018 in the United States and 6 dependent areas, the annual percentage of diagnoses of HIV infection among adults and adolescents attributed to male-to-male sexual contact accounted for over 65% of diagnoses (Figure 5 and Table 1b). From 2014 through 2018 in the United States and 6 dependent areas, among male adults and adolescents, the annual number of diagnosed HIV infections attributed to injection drug use increased (Table 1b). The number of infections attributed to male-to-male sexual contact and heterosexual contact decreased. The number of infections attributed to male-to-male sexual contact and IDU [Injection Drug Use] remained stable. The perinatal and “Other” transmission categories accounted for less than 1% of cases. Among female adults and adolescents, the number of infections attributed to IDU increased. The number of infections attributed to heterosexual contact decreased. The perinatal and “Other” transmission categories accounted for less than 1% of cases."

"The world is not on track to reduce HIV transmission among people who inject drugs by 50%, as recent evidence suggests little change in the HIV burden in this population. HIV prevalence among people who inject drugs remains high – up to 28% in Asia. HIV prevention coverage for people who inject drugs remains low, with only two of 32 reporting countries providing the recommended minimum of at least 200 sterile syringes per year for each person who injects drugs. Among 35 countries providing data in 2013, all but four reached less than 10% of opiate users with substitution therapy. In addition to exceptionally low coverage, an effective AIDS response among people who inject drugs is undermined by punitive policy frameworks and law enforcement practices, which discourage individuals from seeking the health and social services they need."

"Of the estimated 585,000 deaths attributed to drug use in 2017, half are attributed to liver cancer, cirrhosis and other chronic liver diseases related to hepatitis C, which remains mostly untreated among PWID. Deaths attributed to drug use disorders (167,000) account for 28 per cent of all deaths resulting from drug use; 110,000 or 66 per cent of those deaths are attributable to opioids. Over the past decade, the total number of deaths attributed to drug use has increased by a quarter, with a major increase in deaths caused by opioid use disorders (71 per cent increase), followed by cirrhosis and other chronic liver diseases (55 per cent increase) and liver cancer (46 per cent) resulting from hepatitis C.

"The comparison of deaths attributed to drug use among men and women over the past decade shows that the number of deaths attributed to drug use disorders, in particular opioid use disorders, has increased disproportionately among women, with a 92 per cent increase in deaths attributed to opioid use disorders among women compared with a 63 per cent increase among men."

"• In the fifteen-year (2004–2018) combined samples of young adults aged 21–30, 1.5% report having ever used any drug by injection not under a doctor’s orders, and 0.5% reported doing so on 40 or more occasions (Table 4-1a). Thus, about 1 in every 67 respondents has ever used an illicit drug by injection, and about 1 in every 200 respondents reports an extended pattern of use as indicated by use on 40 or more occasions. There are appreciable gender differences—2.2% of males vs. 0.9% of females indicate ever injecting a drug (p<.001), and the percentages saying they injected on 40 or more occasions are 0.7% for males and 0.3% for females (p<.001). The percentages of young adults who have injected drugs during the past 12 months without medical supervision are considerably smaller: 0.5% overall—1 in every 200 respondents—including 0.8% of males and 0.3% of females (p<.001). The percentages using 40 or more times in the past 12 months are 0.2% overall—0.3% for males and 0.1% for females."

"• The proportions of 21- to 30-year-olds who say they have ever shared needles in this way during their lifetime are 0.5% overall—0.6% of males and 0.4% of females (bottom of Table 4-1). As noted in the previous section, 1.5% of the full samples say they have ever injected a drug, so this indicates that a minority—but still a third (0.5%/1.5%)—of the people injecting any of the several drug classes mentioned in the question (heroin, cocaine, amphetamines, and/or steroids) shared a needle at some time.

"• The proportion of 21- to 30-year-olds who reported that they shared needles in the prior 12 months is 0.2%, with no significant gender difference. This compares to 0.5% who said that they have injected a drug in the prior 12 months, so about two fifths of past year injectors shared a needle at least once during the year.

"• Of respondents age 21-30, almost half of females who have injected in their lifetime reported having shared needles (0.4%/0.9%), compared to a little more than one-fourth of male injectors (0.6%/2.2%), suggesting that young adult female injectors are more at risk due to needle sharing. It seems likely that the rates are underestimates for the entire population in this age group due to the omission of high school dropouts, the likelihood that drug-addicted users would be more likely than average to leave the study, and the possibility of some underreporting of this behavior. But while the prevalence of needle sharing is low, it can still translate to sizable numbers of people engaging in shared needle use. An estimated 45 million Americans were between ages 20 and 29 in 2017 (US Census Bureau, 2018); just 0.5% of this group would be approximately 225,000 individuals.

"• To summarize, while young adult men are more likely to inject drugs than their female counterparts, they are only slightly more likely to share needles."

"Injecting drug use is estimated to account for approximately 10 per cent of HIV infections worldwide and 30 per cent of all HIV cases outside Africa,113 while in the eastern countries of the WHO European Region114 more than 80 per cent of all HIV infections occur among PWID [People Who Inject Drugs].115 PWID are estimated to be 22 times more likely than people in the general population to be living with HIV.¹¹⁶

"The 2018 joint UNODC/WHO/UNAIDS/World Bank estimate of the global prevalence of HIV among PWID is 12.6 per cent, amounting to 1.4 million PWID living with HIV. This estimate is based on reporting of the prevalence of HIV among PWID by 121 countries, covering 96 per cent of the estimated global number of PWID. Data on HIV prevalence were available for all PWID in North America, South-West Asia, South Asia, Eastern Europe and South-Eastern Europe, but only for 33 and 32 per cent of all PWID in Central America and the Caribbean, respectively. Of all the countries that provided details of the methodology used to collect their data and estimate the prevalence of HIV, almost three quarters (reports from 89 countries) could be graded as “class A methodology” (seroprevalence study).117 In 2018, new or updated estimates of HIV among PWID were available for a total of 40 countries.

"The subregional prevalence of HIV among PWID continues to be the highest by far in South-West Asia (29.5 per cent) and Eastern Europe (25.2 per cent), followed by Southern Africa (21.4 per cent). In Africa, the HIV prevalence among PWID aged 15–64 was estimated at 11.3 per cent, compared with 3.9 per cent among the general population (aged 15–49) for the same year. In Europe, the HIV prevalence among PWID was 20.2 per cent, compared with 0.4 per cent among the general population.118 HIV prevalence in PWID in East Africa and the Caribbean was also higher than the global average, at 17.4 and 14.0 per cent, respectively.

"The largest number of PWID living with HIV reside in Eastern Europe, East and South-East Asia and South-West Asia, which together account for 67 per cent of the global total. Although the prevalence of HIV among PWID (9.3 per cent) is below the global average, a fifth of the global number of PWID living with HIV reside in East and South-East Asia. A small number of countries continue to account for a large proportion of the total global number of PWID living with HIV. In 2018, for example, PWID living with HIV in China, Pakistan and the Russian Federation accounted for almost half of the global total (49 per cent), while PWID in those three countries comprise only a third of all PWID worldwide."

"At yearend 2021, an estimated 11,810 persons in the custody of state and federal correctional authorities were known to be living with HIV, a decrease of about 2% from yearend 2020 (12,060) (figure 1).1 This decrease followed the largest 1-year decline (down 15% between 2019 and 2020, largely as a result of the COVID-19 pandemic) since data collection began in 1991. The population of state and federal prisoners living with HIV has fallen for 23 straight years from its peak of 25,980 in 1998, largely due to a roughly 4% average annual decrease in state prisoners with HIV."

According to the CDC, Human Immunodeficiency Virus (HIV) disease was the ninth leading cause of death in the US among all people aged 25-34, the eighth leading cause of death among males aged 25-34, and the tenth leading cause of death among males aged 35-44.

"Our systematic review identified 55 NSP unit cost estimates from 14 middle and high-income countries. Higher unit costs were associated with countries with higher HSRI and fewer syringes distributed, and with newer programs, which confirmed our hypothesis. The number of intervention components included was not seen to affect the unit cost, possibly because the majority of programs did not include any additional WHO-recommended intervention components. Using our best performing model, the cost per syringe distributed of a comprehensive NSP was extrapolated to 137 countries. We find that current spend on NSP among 68 countries examined needs to increase by 2.1-times the current spend to achieve the WHO/UNODC/UNAIDS 2020 target goals of 200 syringes distributed per PWID. Reaching the high-coverage targets for NSPs can reduce the burden of HIV and HCV infection among PWID ^[22] and has been found cost-effective in several settings ^[15,23,24]."

"Although model projections can only provide estimates of health benefits and costs, such analyses can provide intuition around critical mechanisms and assumptions to inform decision making. Our main finding is that, over 20 y, high coverage (enrollment of 50% of the eligible population) of OAT [Opioid Agonist Therapy], NSPs [Needle and Syringe Programs], and Test & Treat in combination could avert nearly 43,400 (95% CI: 23,000, 74,000) HIV infections among PWID [People Who Inject Drugs] and reduce HIV prevalence among PWID by 27% (95% CI: 12%, 45%). The construction of such a portfolio has the potential to be cost-effective at each incremental expansion, with projected ICERs below US$50,000 per QALY [Quality-Adjusted Life Year] gained. Moreover, our analysis suggests that the estimated benefit obtainable by PrEP alone (measured in QALYs) could potentially be achieved and even surpassed at substantially lower cost by combining other prevention interventions into high-value portfolios.

"Advocates for efficient investment in PWID-specific interventions have asked, “What good is preventing HIV if we do not first save that life at HIV risk?” [77]. Our analysis suggests that the high competing mortality risks of PWID can explain why interventions that immediately improve quality of life can have substantially higher estimated benefits than those that focus on HIV prevention alone. Our analysis estimates that OAT, in particular, which we assume has a direct impact on the length and quality of life of treated individuals [27,28,30–32,60,61], can provide substantially more benefit, measured in QALYs, than other interventions, even when it prevents fewer infections (Table 2).

"Although our analysis did not identify a scenario in which OAT was not a cost-effective addition to a high-value portfolio, deterministic and probabilistic sensitivity analyses can provide intuition regarding scenarios in which NSPs could replace OAT as the priority investment. Because the assumed delivery cost of NSPs is so much lower than that of other programs, our findings suggest that it is reasonable to invest in NSPs concurrent with OAT scale-up. While Test & Treat is often estimated in our analysis to be a cost-effective addition to the portfolio, our model does not project it to be a priority investment. Our estimates for ART’s reduction of transmission risk via injection-based contact [13,44] are lower than those for sexual contact [14,41,44], which may explain our projection of smaller benefits in the PWID population. It should also be noted that HIV prevalence in US PWID is less than 10% [18], and the direct QALY increases from Test & Treat programs were therefore low relative to programs that served the entire PWID population."

"The infectious disease consequences of injection drug use place a heavy toll on entire communities and are a serious threat to the health and well-being of our nation. The estimated cost of providing health care services to persons living with chronic HCV infection is $15 billion annually.¹⁸ The average cost of a hepatitis A–related hospitalization in 2016 was $16 610, and recent hepatitis A virus outbreaks alone have cost the nation at least $270 million since 2016.¹⁹ In 2019, HIV care and treatment cost the US government more than $20 billion.²⁰ The cost for treating HIV infections related to the Scott County outbreak is projected to be more than $100 million.²¹ SSPs are associated with an approximately 50% reduction in HIV and HCV incidence.¹⁸ A 2019 study in Philadelphia found that SSPs averted 10 582 HIV infections during a 10-year period. This number equates to a 1-year return on investment of $243.4 million.²² By helping reduce the economic burden of drug use and associated infections, SSPs should be considered an important partner in my Community Health and Economic Prosperity initiative, which views community health as inherently linked with economic outcomes.^23"

According to the CDC, Human Immunodeficiency Virus (HIV) disease was the eighth leading cause of death among Black people in the US aged 20-24, the sixth leading cause among Black people aged 35-44, and the eighth among Black people aged 45-54.

HIV disease was the sixth leading cause of death among Black males in the US aged 20-24, the sixth leading cause among Black males aged 25-34, the eighth leading cause among Black males aged 35-44, and the eighth leading cause among Black males aged 45-54.

HIV disease was the ninth leading cause of death among Black females in the US aged 25-34, the seventh leading cause among Black females aged 35-44, and the tenth leading cause among Black females aged 45-54.

"The percentage of State prison inmates who were HIV positive was —

"1.3% of those who never used drugs
"1.7% of those who had ever used drugs
"1.9% of those who used drugs in the month before their current offense
"2.8% of those who had used a needle to inject drugs
"5.1% of those who had shared a needle.

"Like State inmates, Federal inmates who used a needle and shared a needle had higher rates of HIV infection than those inmates who reported ever using drugs or using drugs in the month before their current offense."

"PWID [People Who Inject Drugs] accounted for 9 per cent of new adult HIV infections worldwide in 2020, with the proportion rising to 20 per cent outside sub-Saharan Africa, where HIV disproportionately affects adolescent girls and young women.⁹¹ UNODC, UNAIDS, WHO and the World Bank jointly estimated that in 2020 approximately one in every eight (12.4 per cent, down from 12.6 per cent in 2019) PWID worldwide were living with HIV, amounting to 1.4 million people.

"The latest UNAIDS estimates suggest that in 2020, PWID had a risk of acquiring HIV that was 35 times greater than that of people who do not inject drugs.⁹² This underlines the greater vulnerability of PWID to HIV infection than have other key population groups more likely to be exposed to HIV or to transmit it.^{93, 94}

"As a tool to monitor progress in the testing and treatment of HIV, UNAIDS established the 90-90-90 targets in 2014 with the aim that by 2020, 90 per cent of people living with HIV would know their HIV status, 90 per cent of those diagnosed would be receiving antiretroviral treatment, and 90 per cent of those receiving treatment would have achieved viral suppression.⁹⁵ The sub-population of PWID living with HIV seems to be particularly far from these targets as shown by a study in selected countries in Europe and Central Asia.⁹⁶

"Eastern Europe and South-West Asia continue to be the subregions with the highest estimated prevalence of HIV among PWID, with more than one in four PWID in those two regions living with HIV. According to UNAIDS, Eastern Europe and Central Asia (as defined geographically by UNAIDS) is the region with the world’s fastest growing HIV epidemic, with the annual number of new adult HIV infections increasing by an estimated 43 per cent between 2010 and 2020. This is in contrast to a 31 per cent decline in the annual number of new adult HIV infections globally in the same period.⁹⁷"

"ƒ At yearend 2021, an estimated 11,810 persons with HIV were in the custody of state and federal correctional authorities, down from 12,060 in 2020 (table 1).

"ƒ From yearend 2020 to yearend 2021, the number of males in state and federal prison living with HIV declined from 11,390 to 11,190 (down 2%) and the number of females declined from 670 to 620 (down 7%).

"ƒ From 2017 to 2021, the number of males in state and federal prison who had HIV declined an average of 6% per year, while the number of females with HIV declined an average of 10% per year.

"ƒ At yearend 2021, about 1.1% of persons—1.2% of males and 0.9% of females—in state and federal prison were living with HIV.

"ƒ The number of persons in federal prison living with HIV increased 6%, from 1,144 at yearend 2020 to 1,216 at yearend 2021, while the number in state prison declined 3%, from 10,920 to 10,600. (See appendix table 1.)"

"Data on deaths are no longer presented in this report. BJS ceased collection of detailed mortality data in state and local correctional facilities after the 2019 data year."

"The joint UNODC/WHO/UNAIDS/World Bank estimate of the number of PWID worldwide in 2018 is 11.3 million (range: 8.9 million to 15.3 million), corresponding to 0.23 per cent (range: 0.18 to 0.31 per cent) of the population aged 15–64. This estimate is based on the most recent information available and assessment of the methodologies of the different sources.¹⁰⁸

"There is no change between the 2017 and 2018 estimates of PWID; however, any trend data must be viewed with caution, as methodologies may have changed. The 2018 global estimate of PWID is based on 122 countries, representing almost 90 per cent of the global population aged 15–64, compared with 110 countries in 2017. Of all the available sources in 2018, the estimates for at least 74 countries (61 per cent) were based on a “class A methodology” such as indirect prevalence estimation methods (e.g., the capture-recapture method, network scale-up method and multiplier method).¹⁰⁹

"Owing to the criminalization of drug use, punitive laws, stigma and discrimination against people who use or inject drugs in many parts of the world, conventional survey methods have been found to underestimate the actual population size because of the hidden nature of PWID;^{110, 111, 112} therefore, only indirect methods have been shown to reflect the situation of PWID with greater accuracy. Overall, new or updated estimates of PWID were available for 40 countries in 2018.

"Although the exact extent of injecting drug use is not known, estimates are more precise in some regions than others as a result of better data coverage and/or methodologies and the use of more recent data. Data on PWID vary between the regions in terms of coverage of the total population aged 15–64, with Asia having the highest coverage, at 95 per cent, and Africa having the lowest, at 68 per cent. At the subregional level, North America, South-West Asia, South Asia, Eastern Europe and South-Eastern Europe are fully covered, whereas data on PWID in the Caribbean only covers just over one third of the total population; therefore, data from that subregion must be interpreted with caution. Compared with 2017, coverage of the population in Africa increased substantially overall, from 58 to 68 per cent in 2018.

"The prevalence of PWID aged 15–64 in 2018 continues to be the highest in Eastern Europe (1.26 per cent) and Central Asia and Transcaucasia (0.63 per
cent). Those percentages are, respectively, 5.5 and 2.8 times higher than the global average. More than a quarter of all PWID reside in East and South-East
Asia, although the prevalence itself is relatively low (0.19 per cent). The three subregions with the largest numbers of PWID (East and South-East Asia, North America and Eastern Europe) together account for over half (58 per cent) of the global number of PWID. It is noteworthy that, as in previous years, while three countries – China, the Russian Federation and the United States – account for just 27 per cent of the global population aged 15–64, they are home to almost half (43 per cent) of all PWID."

"We found that in cities with NEPs [Needle Exchange Programs] HIV seroprevalence among injecting drug users decreased on average, whereas in cities without NEPs HIV seroprevalence increased. A plausible explanation for this difference is that the NEPs led to a reduction in HIV incidence among injecting drug users.

"NEPs have the potential to decrease directly HIV transmission by lowering the rate of needle sharing and the prevalence of HIV in needles available for reuse, as well as indirectly through activities such as bleach distribution, referrals to drug treatment centres, provision of condoms, and education about risk behaviour. Although these mechanisms have strong theoretical support, the published evidence for NEP effectiveness is limited. Previous studies of the effect of NEPs on HIV incidence used observational designs or statistical models.

"Observational designs included case studies; crosssectional, serial cross-sectional, and cohort studies (often without comparison groups); and case-control studies.^4,5 Only one study assessed the impact of NEPs on HIV incidence. Des Jarlais and colleagues⁷ estimated that the hazard for incident HIV infection was 3·3 for injecting drug users in four high-seroprevalence cities without NEPs, compared with continuous users of NEPs in New York City. One case study investigated HIV prevention activities for five cities with low seroprevalence, but did not formally compare these with other cities that had high seroprevalence.¹³ The most frequently cited statistical model for assessment of NEP effectiveness was developed by the New Haven NEP evaluators, and is based on the theory that NEPs decrease HIV transmission rates by lowering the time that needles are in circulation.¹⁴

"The conclusion of a 1993 review by a University of California team' was that NEPs are associated with decreased HIV drug risk behaviour and are not associated with negative outcomes, but that there is no clear evidence that they decrease HIV infection rates.⁵ Few new data were available for the most recent US review by the Panel on Needle Exchange and Bleach Distribution Programs,⁴ which concluded that NEPs are effective, but acknowledged that the evidence was weak.

"Our study is distinguished from previous work by its worldwide scope and its design, which compares changes in HIV seroprevalence in cities with and without NEPs, rather than changes within a single city."

"Despite the fact that injecting drug use has led to the widespread transmission of HIV worldwide, the provision of HIV prevention, treatment, and care services to IDU populations remains dismally low. In 2009, only 8 per cent of injecting drug users worldwide enjoyed access to HIV prevention services of any kind, while substitution therapy–i.e. offering users methadone instead of heroin–is permitted in only 70 countries. Needle and syringe exchange programmes are available in only 82 countries."

"In 2002, an estimated 93 percent of persons registered by the government as HIV positive since the beginning of the epidemic were injection drug users. In contrast, in 2002 an estimated 12 percent of new HIV transmission was sexual -- that figure climbed to 17.5 percent in the first half of 2003 -- indicating the foothold that the epidemic is gaining in the general population. The European Centre for the Epidemiological Monitoring of AIDS (EuroHIV), a center affiliated with the World Health Organization, noted that HIV prevalence may have 'reached saturation levels in at least some of the currently affected drug user populations' in eastern Europe, including in Russia, but cautioned against complacency 'as new outbreaks could still emerge among injection drug users…, particularly within the vast expanse of the Russian Federation.' Rhodes and colleagues in a February 2004 article echo this conclusion, noting evidence of recent examples of severe HIV outbreaks among drug users in Russia."

From 2014 through 2018, the annual number and rate of diagnoses of HIV infection in the United States and 6 dependent areas decreased (Table 1b). In the United States and 6 dependent areas, the overall rate in 2018 was 11.5; among adults and adolescents, the rate was 13.6 (Figure 1). From 2014 through 2018, by region, the rate of diagnoses of HIV infection in all regions decreased. In 2018, the rates were 15.6 in the South, 9.9 in the Northeast, 9.7 in the West, and 7.2 in the Midwest (Table 1b)."

"CDC estimates that more than 1.1 million people in the United States (US) are living with HIV infection. Nearly one in five (18.1%) of those people are unaware of their infection. Despite increases in the total number of people in the US living with HIV infection in recent years (due to better testing and treatment options), the annual number of new HIV infections has remained relatively stable. However, new infections continue at far too high a level, with approximately 50,000 Americans becoming infected with HIV each year.
"In 2010, an estimated 47,129 people were diagnosed with HIV infection in the 46 states with confidential name-based HIV infection reporting since at least January 2007. In that same year, an estimated 33,015 people throughout the U.S. were diagnosed with AIDS. Since the epidemic began, an estimated 1,129,127 people in the U.S. have been diagnosed with AIDS.
"An estimated 17,774 people with AIDS died in 2009, and nearly 619,400 people with AIDS in the U.S. have died since the epidemic began."

"In 2009, youths (defined in this report as persons aged 13–24 years), who represented 21% of the U.S. population, comprised 6.7% of persons living with HIV. More than half (59.5%) were unaware of their infection, the highest for any age group ⁽¹⁾."

"Of the estimated 14.0 million (range: 11.2 million to 22.0 million) people who inject drugs worldwide, UNODC estimates that 1.6 million (range: 1.2 million to 3.9 million) are living with HIV. That represents a global prevalence of HIV of 11.5 per cent among people who inject drugs.¹⁵
"Along with the estimates of the total number of people who inject drugs, the global total and prevalence rates of people who inject drugs living with HIV for 2011 is also lower than the estimated 3 million (18.9 per cent prevalence among people who inject drugs) previously presented by the Reference Group to the United Nations on HIV and Injecting Drug Use for 2008. These reduced estimates are in large part a result of the availability of more reliable information on HIV prevalence among people who inject drugs."

"Sex and transmission category: From 2010 through 2014, the rates of deaths for male and female adults and adolescents decreased. The number of deaths among males with diagnosed HIV infection attributed to male-to-male sexual contact, to injection drug use, to male-to-male sexual contact and injection drug use, or to heterosexual contact decreased. The number of deaths among females with infection attributed to injection drug use or to heterosexual contact decreased. The number of deaths among female adults and adolescents with infection attributed to perinatal transmission remained stable. Please use caution when interpreting trend data for children with infection attributed to perinatal transmission: the numbers are small."

The CDC estimates that of the 11,521 male adults or adolescents with a diagnosis of HIV in the US and 6 US dependent territories who died in 2014, in 6,195 cases the disease was reportedly transmitted through male-to-male sexual contact; 2,471 cases were reportedly transmitted through injection drug use; 1,221 cases were transmitted through male-to-male sexual contact and injection drug use; 1,543 cases were reportedly transmitted through heterosexual contact; 31 cases were transmitted through perinatal exposure; and 60 cases were attributed to "other."

The CDC estimates that of the 4,069 female adults or adolescents with a diagnosis of HIV in the US and 6 dependent territories who died in 2014, in 1,426 cases the disease was reportedly transmitted through injection drug use; 2,582 cases were reportedly transmitted through heterosexual contact; 32 cases were transmitted through perinatal exposure; and 28 cases were attributed to "other."

"Human immunodeficiency virus (HIV) disease was not among the 15 leading causes of death in 2009. The age-adjusted death rate for HIV disease declined 9.1% from 2008 to 2009 (Table 16). Historically, HIV disease mortality reached its highest level in 1995 after a period of increase from 1987 through 1994. Subsequently, the rate for this disease decreased an average of 33.0% per year from 1995 through 1998, and 6.3% per year from 1999 through 2009 (23). For all races combined in the age group 15–24, HIV disease was the 12th leading cause of death in 2009—dropping from the 11th leading cause in 2008. HIV disease remained the 6th leading cause of death for the age group 25–44. Among decedents aged 45–64, HIV disease dropped from the 12th leading cause in 2008 to the 13th leading cause in 2009."

"Survival was greatest among children regardless of transmission category, followed by adult and adolescent males with diagnosed HIV infection attributed to male-to-male sexual contact, adult and adolescent males with infection attributed to male-to-male sexual contact and injection drug use, and adult and adolescent females with infection attributed to heterosexual contact. Survival was intermediate among adult and adolescent males with infection attributed to heterosexual contact. Survival was lowest among adult and adolescent males and females with infection attributed to injection drug use."

"There is some controversy over the number of narcotic drug users in Russia. Dr. Vadim Pokrovsky of the Federal AIDS Center said that estimates of the number of active drug users in Russia in February 2004 ranged from 1 to 4 million, and he believed the high end of that range reflected the reality. On February 20, 2004, Alexander Mikhailov, the deputy director of the State Drug Control Committee (SDCC), a federal body, was cited in Pravda as saying that Russia had over 4 million drug users, and that the "gloomy prediction" of his office was that Russia could have over 35 million drug users by 2014. In early January 2004, the executive secretary of the Commonwealth of Independent States, which includes twelve former Soviet states, predicted that in 2010 the twelve countries would have 25 million drug users of whom 10 million would be living with HIV/AIDS, the vast majority in Russia."

AIDS

"From 2009 through 2013, the annual estimated number and the estimated rate of infections classified as stage 3 (AIDS) in the United States decreased (Table 2a). In 2013, the estimated rate of infections classified as stage 3 (AIDS) was 8.4."

According to the CDC, from the beginning of the AIDS epidemic through the end of 2011 there have been a total of 1,190,71 cases of AIDS reported in the US and 6 US dependent territories.

The CDC estimates that of the 939,219 adult or adolescent males who received an AIDS diagnosis from the beginning of the epidemic through 2011, 560,860 cases were reportedly transmitted through male-to-male sexual contact, 201,271 were reportedly transmitted through injection drug use, 83,455 were reportedly transmitted through male-to-male sexual contact and injection drug use, 81,477 were reportedly transmitted through heterosexual contact, and 12,157 were attributed to "other."

The CDC estimates that of the 241,553 adult or adolescent females who received an AIDS diagnosis from the beginning of the epidemic through 2011, 92,833 were reportedly transmitted through injection drug use, 142,153 were reportedly transmitted through heterosexual contact, and 6,567 were attributed to "other."

"From 2009 through 2013, the annual number of infections classified as stage 3 (AIDS) among adult and adolescent males with HIV infection attributed to male-to-male sexual contact, injection drug use, male-to-male sexual contact and injection drug use, or heterosexual contact decreased. The number of infections classified as stage 3 (AIDS) among adult and adolescent females with HIV infection attributed to injection drug use or heterosexual contact decreased."

According to the CDC, from the beginning of the AIDS epidemic through the end of 2011 a total of 9,945 cases of AIDS have been reported in the US and 6 dependent territories among children under age 13 at the time of diagnosis.

"From 2008 through 2011, the annual number of infections classified as stage 3 (AIDS) among adult and adolescent males with HIV infection attributed to male-to-male sexual contact increased. The numbers of stage 3 (AIDS) classifications among males with infection attributed to injection drug use, to male-to-male sexual contact and injection drug use, and to heterosexual contact decreased. The number of infections classified as stage 3 (AIDS) among adult and adolescent females with HIV infection attributed to injection drug use decreased; the number with infection attributed to heterosexual contact remained stable."

"From 2008 through 2010, the overall rates for adult and adolescent males and females decreased. The numbers of deaths of males with stage 3 (AIDS) whose HIV infection was attributed to injection drug use, to male-to-male sexual contact and injection drug use, and to heterosexual contact decreased. The numbers of deaths of males with infection attributed to male-to-male sexual contact and to perinatal transmission remained stable. Among adult and adolescent females, the numbers of deaths of those with infection attributed to injection drug use and to perinatal transmission decreased. The number of deaths of females with infection attributed to heterosexual contact remained stable. Trend data for persons with infection attributed to perinatal transmission should be interpreted with caution because numbers are small."

The CDC estimates that of the 11,923 male adults or adolescents with diagnosed HIV infection which was ever classified as stage 3 (AIDS) who died in 2010, 5,980 of the cases were reportedly transmitted through male-to-male sexual contact (MSM), 2,907 were reportedly transmitted through injection drug use, 1,258 were reportedly transmitted through male-to-male sexual contact and injection drug use, 1,654 were reportedly transmitted through heterosexual contact, 26 were reportedly transmitted through perinatal exposure, and 97 were attributed to "other."

The CDC estimates that of the 4,170 female adults or adolescents with diagnosed HIV infection which was ever classified as stage 3 (AIDS) who died in 2010, 1,563 were reportedly transmitted through injection drug use, 2,540 were reportedly transmitted through heterosexual contact, 38 were reportedly transmitted through perinatal exposure, and 29 were attributed to "other."

In 2010, a total of 16,093 persons in the US and 6 dependent areas were estimated to have died with a diagnosed HIV infection ever classified as stage 3 (AIDS). From the beginning of the epidemic through 2010, an estimated 658,992 persons in the US and 6 dependent areas are estimated to have died from AIDS.

"Of the estimated 398,057 male adults and adolescents living with HIV/AIDS, 64% had been exposed through male-to-male sexual contact, 16% through injection drug use, 12% through high-risk heterosexual contact, and 7% through both male-to-male sexual contact and injection drug use. Of the estimated 146,692 female adults and adolescents living with HIV/ AIDS, 72% had been exposed through high-risk heterosexual contact, and 26% had been exposed through injection drug use."

^{Editor's Note: The CDC defines high-risk heterosexual contact as "heterosexual contact with a person known to have, or to be at high risk for, HIV infection."}

"Through 2007, a total of 1,030,832 persons in the United States and dependent areas had been reported as having AIDS (Table 16). Three states (California, Florida, and New York) reported 43% of the cumulative AIDS cases and 36% of AIDS cases reported to CDC in 2007. In the 50 states and the District of Columbia, the rate of reported AIDS cases in 2007 was 12.4 per 100,000 population. When the U.S. dependent areas were included, the rate of reported AIDS cases ranged from zero per 100,000 (American Samoa, Guam, and the Northern Mariana Islands) to 148.1 per 100,000 (District of Columbia)."

"Global expenditure on HIV/AIDS has increased substantially in the last decade, with total annual resources from all sources reaching over $11.3 billion in 2007 and $13.7 billion in 2008.³⁷ Most of these resources are destined for low and middle income countries and include the expenditure allocated to HIV/AIDS prevention, care, treatment and support."

"The Global Fund [to Fight AIDS, Tuberculosis and Malaria]’s annual HIV/AIDS disbursement was approximately $1 billion in 2007,³⁹ $1.6 billion in 2008 and $2.8 billion in 2009.⁴⁰ From 2002 to 2009 the Global Fund has approved a total grant amount of $10 billion for HIV/AIDS prevention, treatment and care. For the 2008 to 2010 biennium, $9.7 billion has been pledged to the Global Fund for all activities by countries and private donors."⁴¹

"The total resources made available for HIV/AIDS increased from $7.9 billion in 2005 to $13.8 million in 2008. Nevertheless, there continues to be a resource gap. UNAIDS estimates that overall the funding needed in 2007 was $18 billion,⁴⁵ indicating that resources need to be increased by about 60%."

"UNAIDS estimates that the total global resources needed for HIV/AIDS for the period 2009 to 2013 is almost $200 billion to achieve universal access by 2010, and $140 billion for a slower scale-up to achieve universal access by 2015.⁸³
"The UNAIDS estimates for harm reduction assume 60% coverage for needle and syringe programmes and 40% for opioid substitution therapy.⁸⁴ These estimates are based on the resources needed for prevention-related activities in order to reach 6.2 million people who inject drugs by 2010 in 132 lower and middle income countries. UNAIDS assumes the cost of opioid substitution therapy using methadone to be between $363 and $1,057 per person per year (which is higher than other estimates in Table 4) and the costs of needle and syringe programmes to be $10 per person per year (lower than other estimates in Table 3).
"Using these figures, UNAIDS estimates that the resources needed for harm reduction are $2.13 billion in 2009 and $3.2 billion in 2010, an average of $170 and $256 respectively per injector per year. Additional resources will be required for antiretroviral treatment, care and support."⁸⁵

"By far the highest prevalence of HIV among PWID [People Who Inject Drugs] is in South-West Asia and in Eastern and South-Eastern Europe, with rates that are, respectively, 2.4 and 1.9 times the global average. Together, those two subregions account for 49 per cent of the total number of PWID worldwide living with HIV. Although the prevalence of HIV among PWID in East and South-East Asia is below the global average, 24 per cent of the global total of PWID living with HIV reside in that subregion. An estimated 53 per cent of PWID living with HIV worldwide in 2016 (662,000 people) resided in just three countries (China, Pakistan and the Russian Federation), which is disproportionately large compared with the percentage of the world’s PWID living in those three countries (35 per cent)."

The lifetime cost of treating an HIV positive person was estimated in 1997 to be $195,188.

"At approximately $160 million in 2007, the estimated total spending on HIV-related harm reduction in low and middle income countries is extremely low, and would still be insufficient even if this figure was underestimated by a factor of two or three. It amounts to about three US cents a day, or $12.80 a year, for each person who injects drugs. It is clearly inadequate when compared with indicative unit costs of providing needles and syringes (approximately $100 per person per year) and methadone (approximately $500 per person per year)."

"Prevention of HIV is also cheaper than treatment of HIV/AIDS. For example, in Asia it is estimated that the comprehensive package of HIV-related harm reduction interventions costs $39 per disability-adjusted life-year saved,¹⁴ whereas antiretroviral treatment costs approximately $2,000 per life-year saved. Such figures demonstrate that harm reduction is a low-cost, high-impact intervention."

"The joint UNODC/WHO/UNAIDS/World Bank estimate for the number of people who inject drugs (PWID) for 2014 is 11.7 million (range: from 8.4 to 19.0 million), or 0.25 per cent (range: 0.18-0.40 per cent) of the population aged 15-64. PWID experience some of the most severe health-related harms associated with unsafe drug use, overall poor health outcomes, including a high risk for non-fatal and fatal overdoses, and a greater chance of premature death.⁹⁷ This is exacerbated by poor access to evidence-informed services for the prevention and treatment of infections, particularly HIV, hepatitis C and tuberculosis.⁹⁸

"Eastern and South-Eastern Europe is the subregion with by far the highest prevalence of injecting drug use: 1.27 per cent of the population aged 15-64. The subregion accounts for almost one in four (24 per cent) of the total number of PWID worldwide; almost all PWID in the subregion reside in the Russian Federation and Ukraine. In Central Asia and Transcaucasia and in North America, the prevalence of injecting drug use is also high: 0.72 per cent of the population aged 15-64 in Central Asia and Transcaucasia; and 0.65 per cent in North America. Those three subregions combined account for 46 per cent of the total number of PWID worldwide. Although the prevalence of injecting drug use in East and South-East Asia is at a level below the global average, a large number of PWID (27 per cent of the total number of PWID in the world) reside in the subregion, given that it is the most populated subregion. Three countries (China, Russian Federation and United States) together account for nearly half of the total number of PWID worldwide."

From 2000 through 2014, a total of 569 people died from AIDS-related illnesses while serving time in a local jail in the US. Of those, 98 were white non-Latinx, 395 were black non-Latinx, 73 were Latinx, and 3 were "other."
In 2015, a total of 10 people serving time in local jails in the US died from AIDS-related illnesses.

"Between 2001 and 2010, the estimated number of inmates with HIV/AIDS declined by 16%, and the number of AIDS-related deaths in prison declined by 77% (not shown in table) resulting in declines in the rates of HIV/AIDS and AIDS-related deaths among all inmates and those with HIV/AIDS. At yearend 2001, the estimated rate of HIV/AIDS among state and federal prison inmates was 194 HIV/AIDS cases per 10,000 inmates. By yearend 2010, the estimated rate was 146 cases per 10,000. Among the total inmate population, the rate of AIDS-related deaths declined from 24 per 100,000 inmates in 2001 to 5 per 100,000 in 2010. Among the inmate population with HIV/AIDS, the rate declined from 134 AIDS-related deaths per 10,000 inmates in 2001 to 38 per 10,000 in 2010."

"The rate of AIDS-related deaths in state prisons among inmates ages 15 to 54 declined sharply between 2001 and 2009, compared to the more modest decline observed among the same age group in the U.S. general population. As a result, the AIDS-related death rate in state prisons fell below the rate in the U.S. general population in 2009. Between 2001 and 2009, the AIDS-related death rate among state prisoners ages 15 to 54 declined from 22 deaths per 100,000 inmates to 6 per 100,000, while the rate among that age group in the general population declined from 9 per 100,000 to 7 per 100,000."

"In personal interviews conducted in 2002, nearly two-thirds of local jail inmates reported ever being tested for HIV; of those, 1.3% disclosed that they were HIV positive."

"Among jail inmates in 2002 who had ever been tested for HIV, Hispanics (2.9%) were more than 3 times as likely as whites (0.8%) and twice as likely as blacks (1.2%) to report being HIV positive."

"We reviewed evidence from more than 900 studies and reports on the link between human rights abuses experienced by people who use drugs and vulnerability to HIV infection and access to services. Published work documents widespread abuses of human rights, which increase vulnerability to HIV infection and negatively affect delivery of HIV programmes. These abuses include denial of harm-reduction services, discriminatory access to antiretroviral therapy, abusive law enforcement practices, and coercion in the guise of treatment for drug dependence. Protection of the human rights of people who use drugs therefore is important not only because their rights must be respected, protected, and fulfilled, but also because it is an essential precondition to improving the health of people who use drugs. Rights-based responses to HIV and drug use have had good outcomes where they have been implemented, and they should be replicated in other countries."

"The global war on drugs is driving the HIV/AIDS pandemic among people who use drugs and their sexual partners. Throughout the world, research has consistently shown that repressive drug law enforcement practices force drug users away from public health services and into hidden environments where HIV risk becomes markedly elevated. Mass incarceration of non-violent drug offenders also plays a major role in increasing HIV risk. This is a critical public health issue in many countries, including the United States, where as many as 25 percent of Americans infected with HIV may pass through correctional facilities annually, and where disproportionate incarceration rates are among the key reasons for markedly higher HIV rates among African Americans."

"Recommendation 1. Local service planners need to review local needle and syringe services (and be supported in this work) in order to take steps to increase access and availability to sterile injecting equipment and to increase the proportion of injectors who receive 100 per cent coverage of sterile injecting equipment in relation to their injecting frequency."

"Smoking of crack cocaine was found to be an independent risk factor for HIV seroconversion among people who were injection drug users. This finding points to the urgent need for evidence-based public health initiatives targeted at people who smoke crack cocaine. Innovative interventions that have the potential to reduce HIV transmission in this population, including the distribution of safer crack kits and medically supervised inhalation rooms, need to be evaluated."

"Short-term use of smoked cannabis did not affect viral load in 15 HIV-positive patients and also is associated with adherence to therapy and reduced viral loads in 16 patients with hepatitis C infections."

"The percentage of jail inmates reporting that they were HIV positive varied by level of prior drug use. Of jail inmates who reported never using drugs, 0.4% were HIV positive. An estimated 1.5% of inmates who had ever used drugs, 1.5% of those who used drugs in the month before their current offense, 3.2% of those who had used a needle to inject drugs, and 7.5% of those who had shared a needle reported being HIV positive."

"Those inmates held for a property offense in local jails reported the highest HIV positive rate (1.8% ) (table 10). Drug offenders reported a slightly lower rate (1.6%). The percentage of public-order offenders who were HIV positive was 1.1%; the percentage of violent offenders, 0.7%."

"Russia now has a 1 percent HIV prevalence rate among its young people and the fastest growing HIV/AIDS epidemic in the world. While the epidemic is still predominantly fuelled by injecting drug users and confined to their ranks, there are clear signs that the epidemic continues to spread to the general population, especially the youth."

"The epidemic disproportionately affects IDUs who comprise 87% of the cumulative number of registered HIV cases, however, with the epidemic becoming more mature, the infection tendency away from IDUs to heterosexual is also increasing with 68% of newly registered cases by the end of 2004 corresponding to IDU and 30% to heterosexuals (In the previous year heterosexual transmission accounted for 23.4% of new infections). The interpretation of the tendency towards less new infections diagnosed is not an indication of a slowing of the epidemic but rather reflective of the changes in HIV testing policy, the smaller number of tests performed in population groups with high-risk behaviors and also a shortage of test kits."

"Eastern Europe, the Commonwealth of Independent States, and significant parts of Asia are experiencing explosive growth in new HIV infections, driven largely by injecting drug use (UNAIDS, 2006). While the primary route of transmission in most of these areas is sharing of contaminated injecting equipment, sexual and perinatal transmission among IDUs [injecting drug users] and their partners also plays an important and growing role. In many highly affected countries, rapid growth in the number of IDUs infected with HIV has already created a public health crisis. Countries where the level of HIV infection is still relatively low have the chance -- if they act now -- to slow the spread of HIV."