Substance use and universal access to HIV testing and treatment in sub-Saharan Africa: implications and research priorities

Abstract

As universal testing and treatment for HIV, or 'treat all', expands across sub-Saharan Africa (SSA), substance use will likely have a negative impact on the success of scale-up efforts for antiretroviral treatment (ART). Overwhelming evidence highlights the negative impact of substance use on HIV care and treatment outcomes. Yet, as many countries in SSA expand ART, evidence of the extent of substance use, and its impact in the region, is more limited. Stigma, and the psychoactive effects of substance use, are barriers to seeking HIV treatment and adhering to ART regimens for persons with heavy alcohol use or substance use. As a result, we identified several implementation and operations research priorities and metrics for monitoring the impact of substance use and Treat All. Identifying barriers and facilitators to the integration of the prevention and treatment of substance use with HIV care, and assessing effects on HIV outcomes, through longitudinal studies are priorities that will determine the impacts of substance use on 'treat all' in SSA. Future research must use existing infrastructure, including large networks of HIV clinics, to enhance our understanding of the implementation and service delivery of substance use screening, referral and treatment. These networks will also inform robust and standardised substance use estimates and interventions within the 'treat all' era in SSA.

Keywords: injection drug use, non-injection drug use, alcohol, antiretroviral treatment, Africa.

Figure 1.

All panels were created using ArcGIS Desktop (Release 10, Environmental Systems Research Institute, Redlands, CA, USA). Evidence of substance use, including: (a) Total annual alcohol per capita consumption of those 15 years or older in litres of pure alcohol as stated in each country's profile in the WHO's 2014 Global Status Report on Alcohol and Health was used . In an effort to discern low and high rates of alcohol use in each country, the United King­dom's alcohol guidelines were used to differentiate levels of alcohol use. The UK guidelines recommend no more than 14 units of alcohol (140 mL of pure alcohol) per week or 7.28 L of pure alcohol per year; (b) Injection drug use-prevalence data were pulled from a systematic review by Degenhardt et al ; and (c) non-injection drug use within sub-Saharan Africa. A combina­tion of search techniques was implemented to find evidence of non-injection drug use of cocaine , heroin and methamphetamine within each country in SSA. The United Nations Office on Drugs and Crime Statistics Online Tool was used to determine prevalence of amphetamine and cocaine use by country. If no data were available, then PubMed and Google Scholar search functions were used with each country's name and ‘cocaine’, ‘heroin’, ‘methamphetamine’, or ‘ampheta­mine’ to find studies that documented non-injection use from the year 2000 to the present. All non-injection drug use sources were combined to create Figure 1c.