HIV counseling and testing among injection drug users needs to continue.

Abstract

We were interested in the article by Heimer et al.1 that investigated the proportion of injection drug users (IDUs) who were aware and unaware of their HIV serostatus and how this could impact expansion of HIV counseling and testing and prevention efforts. Data from the Centers for Disease Control and Prevention (CDC) have demonstrated a decline in HIV diagnoses attributed to injection drug use, and we recently confirmed a similar decline from 1990 to 2003 in Rhode Island.2,3 Heimer et al. estimated that the number of IDUs unaware of their HIV infection represented a small proportion of the general IDU population. Therefore, they questioned whether resources should be expended to expand HIV counseling and testing programs targeting IDUs. We are concerned that this conclusion may send the wrong message. HIV counseling and testing programs have been a cornerstone of HIV prevention for IDUs. Programs implemented in conjunction with syringe exchange, substance abuse treatment, and correctional settings have contributed to the decrease in injection drug use–related HIV diagnoses. It is difficult to determine the relative impact of HIV counseling and testing as a prevention strategy compared with other effective strategies, such as syringe exchange and methadone maintenance treatment. However, studies have demonstrated a reduction in HIV risk behavior among HIV-infected IDUs after learning of their infection.4 Rapid HIV testing can be used effectively in settings where IDUs may not return for test results, such as jails, where incarceration times can be brief.5 Furthermore, the population of IDUs is not static. According to the recent Youth Risk Behavior Survey, 2.1% of high school students surveyed had participated in illegal injection drug use, which is likely an underestimation, given that this only accounted for youth attending school.6 CDC data have suggested that the population of IDUs has increased, especially among persons aged 18–25 years, and particularly in suburban and rural areas.7 As persons enter the injection drug use community, access to HIV counseling and testing must be assured. The question is whether current HIV counseling and testing for IDUs needs to be expanded. The decline in HIV attributable to IDU is encouraging and arises from a combination of prevention efforts, of which HIV counseling and testing has been prominent. We caution against concluding that HIV counseling and testing does not need to be expanded among IDUs and encourage investigation into those programs where an expansion of HIV counseling and testing is needed most—rapid HIV testing in jails, focused HIV counseling and testing among specific minority populations, and expansions of HIV counseling and testing among non-IDUs, particularly those most at risk of becoming IDUs themselves.