In the final decade before the United Nations’ 2030 deadline to “end AIDS,” a sprawling coalition of activists from Africa, Asia, the Americas and Europe is calling on UNAIDS—the UN’s arm dedicated to HIV/AIDS issues—to dedicate resources to researching treatment for, and delivering harm reduction services to, people living with stimulant use disorders, which carry HIV transmission risks.
In a January 25 letter addressed to Krittayawan Boonto, UNAIDS coordinator of strategy development, and exclusively obtained by Filter, a group of 31 representatives from leading drug-user organizations and 15 individual stimulant experts outlined three simple demands. They’re aimed at ensuring that the international body’s next global AIDS strategy, to be considered for adoption on March 24, provides much-needed public health resources to people who use crack and cocaine hydrochloride, methamphetamine,and New Psychoactive Substance (NPS) stimulants—all of which are associated with increased HIV transmission risks.
Firstly, UNAIDS should dedicate “additional investment” to on-the-ground “stimulants response” programs, like tried-and-true safer smoking kit distribution, through “development, research, community mobilisation and capacity building,” the co-signatories declare.
Secondly, there’s a dire need for “proper investment and research into treatments with (safer) agonist medications” for people who use the three groups of stimulants. This piece is critical, Secretariat Mat Southwell of the UNODC Civil Society Group on Drug Use and HIV, a veteran international drug-user organizer, told Filter.
“We know what works [regarding stimulant harm reduction, as addressed in the first demand]. Those are well studied. They just need to scale. The most underdeveloped area is the stimulant use disorder treatment,” he said.
Lastly, the advocates request that the finalized strategy cite a 2019 technical guidance by UNAIDS, UNODC (the UN Office on Drugs and Crime) and the World Health Organization on HIV prevention among people who use stimulants, and UNODC’s 2019 discussion paper. Their inclusion would cement the international governance body’s endorsement of interventions recommended by drug-user activists.
Of the scientific and political interest in stimulant use disorders that does exist in the United States, much focuses on non-pharmacological interventions—like contingency management, or non-euphoric medications like naltrexone, bupropion and mirtazapine. Pharmacological research wasn’t even noted in the US federal government’s June 2020 “Treatment of Stimulant Use Disorders” resource guide; it just noted that the Food and Drug Administration has yet to approve a medication.
When stimulant agonist medications, like dextroamphetamine, are mentioned, it’s often with questionable caveats. New York State’s February 2020 guidance stressed that prescribers should “judiciously” prescribe “controlled substances with misuse or diversion potential” if the person lives with a stimulant use disorder and should “ensure frequent and careful monitoring.” It’s the same shaky reasoning that’s been undermined by the success of more methadone take-homes for people living with opioid use disorders amid the COVID-19 crisis.
In contrast to the current SUD medication trajectory in the US, the letter authors highlight the promise of dextroamphetamine and Ritalin, noting the attention given to the two drugs by the UN Office on Drugs and Crime (UNODC), whose 2019 discussion paper was formed through the expert contributions of Southwell and about 14 other professionals with lived experience. Examining studies conducted from 2001 to 2016, the paper found that amphetamine agonists “seem to offer benefits in the treatment for cocaine use disorder with less support for treatment of amphetamine use disorder.”
With dextroamphetamine, the “worst-case scenario is you experience psychosis, which is rare,” said Southwell, who is excited about its potential for success. “It’s ridiculous that something that’s been studied since the 1960s has never been invested in”—even though he says people have themselves been “getting into” these substances to self-medicate their stimulant use disorders.
It sounds like a negative feedback loop: scant literature perpetuating lack of attention. “Its efficacy has been questioned because of the limited research base,” the letter states. “We call for a proper investment and research into treatments with (safer) agonist medications with people who use these 3 stimulant drugs associated with HIV transmission.”
Stimulant Supplemental Advocacy Letter FINAL
Stimulant activists’ January 25 advocacy letter (Courtesy of Southwell)
How They Got Here, Where They’re Going
The demands are, in part, a response to what the coalition describes as “clear HIV outbreaks” among people who use at least one of the three specified types of stimulants. In particular, the letter notes the “strong intersectionality” of the outbreaks within queer and trans chemsex scenes and paid sex economies.
For Southwell, the case of Romania illustrates what’s at stake for stimulant users. Between 2009 and 2010, people there who injected heroin rapidly switched to injecting synthetic cathinones, a November 2012 report chronicled. By 2011, a country with historically low HIV seroconversions saw a leap in new infections, from 12 in 2009 to 129. The next year, a survey found that half of injection drug users in Bucharest, the capital, tested HIV-positive. All this occurred as harm reduction services were slashed due to the end of Global Fund and UNODC funding.
“The problem is drug scenes can change really fast. That’s an example of an injecting stimulant scene jumping off the ground,” Southwell commented.
Despite the startling injection-driven outbreak, when it comes to stimulants, the “biggest HIV risks,” the coalition writes, concentrate around sex, mostly because of “boundary blurring and compulsivity.” Stimulants’ unique HIV risks can sometimes get lost in North American discourse, as syringe exchanges have formed the basis of the response to the high-profile drug issue of the day—the opioid-involved overdose crisis. That’s not to imply that syringe service programs have nothing to contribute to prevent non-injection, stimulant-involved HIV transmission; indeed, such programs, for example by distributing safe consumption supplies, can provide a point of access to stimulant-related HIV care and prevention.
As 2020 closed, the world had failed to hit the UN’s target epidemic indicators. If countries had stayed on track, the world, would today have 3.5 million fewer HIV infections and 820,000 individuals wouldn’t have died from AIDS, according to a December 2020 report authored by UNAIDS Executive Director Winnie Byanyima, who wrote that the shortcoming is “unacceptable.”
The latest publicly available draft of the Global AIDS Strategy, as of November 20, 2020, did not include a single mention of stimulants. The letter’s recipient, Boonto, did not respond to Filter‘s request for comment.
But Southwell is confident that the demands will make it into the final document. He reported the recommendations to be well received by those working on the strategy. Brazil and Vietnam—known for their crack and meth scenes, respectively—apparently called attention at a UNAIDS Programme Coordinating Board Meeting to the risks of HIV transmission among people who use stimulants, according to activists. The two countries, as well as Ukraine, also figured as key advisors in the development of the technical guidances that the advocacy letter signatories are hoping is cited in the forthcoming Strategy.
Even if stimulant users are sidelined, there would still be exciting confirmed additions, said Southwell. In particular, UNAIDS aims to make almost a third (30 percent) of all HIV-related service delivery run by directly impacted communities. “The dominant focus on community-led services is a significant change,” he stressed.
As a result of the advocacy letter, its signatories have formed new coalition. “It’s important to highlight that the people who worked on this are now setting up the Stimulants Expert Group,” Southwell said. In an email thread among European chemsex activists reviewed by Filter, excitement abounded. “Thanks for this impetus, it’s an excellent initiative and we would love to be involved,” emailed one harm reduction worker. Another: “Exciting times. Great to see this moving.”