NAIROBI, 24 June 2009 (IRIN) - The US President's Emergency Plan for AIDS Relief (PEPFAR) could do more to prevent HIV transmission among injection drug users (IDUs) in Africa, said a recent article in British Medical Journal, The Lancet.

"The programme has supported some projects in sub-Saharan Africa that provide outreach and education to drug users, but it has not funded initiatives that would have a direct and relevant effect on HIV in this population, e.g. needle exchanges, treatment for drug dependency, and antiretroviral therapy targeted to drug users," the authors commented.

Researchers have estimated that 1.2 million deaths in Africa were averted between 2004 and 2007 as a direct result of interventions funded by PEPFAR.

However, HIV activists have heavily criticised its prevention track record, including stipulations that one-third of funding be spent on programmes promoting abstinence outside of marriage, and limited funds for progammes targeting high-risk populations such as sex workers and intravenous drug users.

PEPFAR was reauthorized for an additional five years in 2008, but stayed mute on the issue of needle-exchange initiatives; media reports quoted former US Global AIDS Coordinator Mark Dybul as saying that it would be up to President Barack Obama's administration and the US Congress to decide whether to implement such programmes.

In Kenya, PEPFAR representatives were reluctant to comment on the Lancet report but said in a statement: "Our work with IDUs and non-injecting drug users is part of a balanced prevention portfolio that reflects the drivers of the epidemic in Kenya."

Although heterosexual transmission is still the main means of HIV infection, in sub-Saharan Africa there could be up to three million people who inject drugs, with more than 200,000 in Kenya and at least 250,000 in South Africa; prevalence is often higher among intravenous drug users than in the general population.

"The criminal nature of drug use in these countries means drug users are usually arrested and imprisoned, rarely ever getting treatment for their addictions," Anne Gathumbi, of the Open Society of East Africa, a think-tank based in Nairobi, the Kenyan capital. "The few treatment programmes that exist are mainly detox centres with very high rates of relapse."

Gathumbi told IRIN/PlusNews noted that many of the HIV prevention methods prescribed by the UN World Health Organization, including needle exchange programmes and the use of methadone as a heroin replacement, were discouraged or illegal in many African countries, making it difficult for agencies to provide effective HIV prevention to IDUs.

"A ban on use of US funds for domestic needle exchange programmes does not apply to international initiatives, but PEPFAR managers have acted as though it does," the authors of the article noted. "US President Obama has stated that he favours lifting the ban."

PEPFAR could work with other organizations to lobby governments to change these policies, Gathumbi said. "If they made a concerted effort with other agencies to present evidence of the success of needle exchange programmes in preventing new infections elsewhere, they could bring about a shift in policy."

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